Teres Minor

The Teres Minor is one of the four muscles that comprise the Rotator Cuff which collectively are the primary dynamic stabilisers of the Glenohumeral Joint and consequently, of The Shoulder Girdle . Of these muscles, the Teres Minor is the most inferiorly situated, spanning between the Lateral Scapula and Proximal Humerus .


Structure

With “teres” in reference to its round stature, the Teres Minor is a narrow muscle that extends from the Lateral Border of the Scapula to the Greater Tuberosity of Humerus (SOURCE-21+23). The Teres Minor is described to have two distinct portions (SOURCE-18+21):

  • Upper Portion - arises from the upper two-thirds of the dorsal surface of the Lateral Border of Scapula . This portion is described to have a pennate Muscle Architecture and large intramuscular tendon

  • Lower Portion - arises from two aponeurotic laminae that distinguish the Teres Minor from the Infraspinatus and Teres Major . This portion is described to have a fusiform Muscle Architecture

As the fibres course superolaterally they become tendinous with typical insertion on the Posterior Glenohumeral Joint Capsule and posteroinferior Greater Tuberostiy of Humerus (SOURCE-21+23). Lower fibres make direct humeral attachment above the origin of the Lateral Head of Triceps , forming two of the four walls that define an anatomical landmark known as theQuadrilateral Space(SOURCE-23). Enclosed also by borders of the Teres Major and Surgical Neck of Humerus , this space forms a passageway for neurovascular structures such as the Axillary Nerve .

Innervation

The Teres Minor receives nervous innervation from the Axillary Nerve from C5 and C6 Nerve Root s.

Muscle Architecture

The Teres Minor exhibits a parallel Muscle Architecture , as indicated by an absence of pennation (0º angulation). Its muscle fibres are notably long, extending almost the entire length of the muscle. This parallel design facilitates efficient force transmission along the line of muscle pull and suggests an emphasis on generating movement across a greater range of motion.As one of the smaller muscles of the Rotator Cuff , the Teres Minor possesses a relatively modestPhysiological Cross-Sectional Area (PCSA). While certain metrics are heavily contingent on the population evaluated and measurement methodology, the following has been reported:5 cadavers, average age of ~73 years (SOURCE-6):

  • PCSA - 1.26 ± 0.34 cm²

  • Muscle Length - 95 ± 5mm

  • Muscle Fibre Length - 85 ± 5mm

  • Pennation Angle - 0º

  • Muscle Mass - 11 ± 3g

MRI of 10 subjects (5 female, 5 male) 24-37 years, 158-188cm tall and a bodyweight of 50-86kg (SOURCE-7):

  • PCSA - 3.7 ± 1.5 cm²

  • Total Muscle Volume - 28.0 ± 13.9 cm³

  • Total Muscle Length - 11.5 ± 1.7 cm

Variation

The Teres Minor has been described to fuse with the Infraspinatus (SOURCE-21).


Function

Collectively the Rotator Cuff affords dynamic stability to the Glenohumeral Joint , in part through its regulation of the arthrokinematics and contraction on the Glenohumeral Joint Capsule (as described on its page) (SOURCE-17). Like the Subscapularis and Infraspinatus , the Teres Minor has an inferiorly directed translation force on the Head of Humerus which offsets the notable superior pull over the Deltoid during arm elevation and helps prevent impingement during the second half of the movement (SOURCE-17). Furthering this notion, the posterior cuff ( Infraspinatus and Teres Minor) stabilises The Shoulder Girdle against shear forces from other cuff muscle s, in particular those that are anteriorly directed and affords the essential GH Joint - External Rotation force required during arm elevation to clear the Greater Tubercle from under the Acromion (SOURCE-17+23).

The extent to which the Teres Minor contributes to GH Joint - External Rotation is contingent on arm position. Between 0 and roughly 60º of GH Joint - Abduction , the Infraspinatus has the more favourable Moment Arm and therefore contributes a greater amount, with the Teres Minor contributing ~25% of the overall GH Joint - External Rotation Torque (SOURCE-18+23). As the arm is elevated futher, the moment arm for Teres Minor becomes more favorable and by 90º GH Joint - Abduction the muscle produces the predominant External Rotation force (SOURCE-18+23). With its pennate architecture and large intramuscular tendon , it is through the Upper Portion of Teres Minor is more suited to this External Rotation role (SOURCE-18). Conversely, the Lower Portion appears more suited to stabilise and depress the Head of Humerus beyond 90º of arm elevation (SOURCE-18). This divergence in roles between the two portions may be supported by the fact that despite an exertional contration producing GH Joint - External Rotation and GH Joint - Adduction , the Teres Minor may still contribute ~10% to the overall arm elevation torque (SOURCE-18).

In terms of EMG readings and overall Torque production, Teres Minor is believed to contribute the least to the overall function of the Rotator Cuff ; however, its lack of tendinous interaction with the Rotator Cable and adjacent Infraspinatus leaves it less frequently subject to propagating tears (SOURCE-18+23). Consequently, the unaffected Teres Minor often plays an integral compensatory for Rotator Cuff insufficiency (SOURCE-23).


Pathomechanics

The relative lack of impingement risk and continuity with the Rotator Cable leaves the Teres Minor at less risk of traumatic or degenerative injury when compared to the other Rotator Cuff muscles (SOURCE-18+23). More frequently, the Teres Minor serves an integral compensator in the presence of Rotator Cuff pathology to maintain adequate joint arthrokinematics and GH Joint - External Rotation (SOURCE-18+23). This compensatory function is emphasised by the fact that the Teres Minor often displays activity-derived hypertrophy in the presence of massive Rotator Cuff Tears (SOURCE-23).

Tears

Tears of the Teres Minor are rare, present in only ~0.9% of Rotator Cuff Tear s, with no isolated tears reported in the literature (SOURCE-23). Teres Minor tears are included in description of posterior and posterosuperior cuff tear s, with the former often compromising GH Joint - External Rotation while the latter, arm elevation (SOURCE-23). Approximately a third of those that did have a Teres Minor tear displayed these movement deficits (SOURCE-18).

In the presence of Supraspinatus or Infraspinatus Tear s, the Teres Minor must provide a greater force to counteract the pull of the Subscapularis (SOURCE-23).

Neurological

In terms of degeneration, the Teres Minor is particularly vulnerable to neurological injury as there are several sites of vulnerability along its innervation pathway that have subtle distinctions in their presentation:

  • Quadrilateral Space Syndrome (QSS)- the narrow Quadrilateral Space (described inStructure)forms a passage for the Axillary Nerve and Posterior Humeral Circumflex Artery which may be subject to compression when this space is reduced (SOURCE-23+24). Both neurovascular structures bifurcate near this space into anterior and posterior branches, for the Axillary Nerve this division happens within the space in 88% of specimens (SOURCE-24). As multiple structures are therefore potentially implicated, this syndrome has distinct clinical manifestations based on the neurovascular structure(s) that has been compromised:Anything that encroaches on the Quadrilateral Space has the capacity to compress the neurovascular structures, most commonly this is attributed to thick fibrous bands that extend from the Long Head of Triceps Fascia to the Teres Minor (SOURCE-24). These bands are pulled taut during movements such as GH Joint - Abduction , GH Joint - External Rotation and GH Joint - Internal Rotation , making these motions provocative (SOURCE-24). Other known causes include Muscle hypertrophy with repetitive overhead movements or space occupying lesions such as paralabral cysts, bony Fracture fragments and benign tumours (SOURCE-24).

    • Neurologic QSS - compression of the Axillary Nerve or one of its major branches results in generalised pain within The Shoulder Girdle that may be felt more posteriorly and altered sensation of its cutanous branches which supply the skin over the distal two-thirds of the posterior deltoid (SOURCE-23+24). Compression of the posterior branch may compromise motor function of the Teres Minor and Posterior Deltoid , while compression of the anterior branch may compromise the Anterior and Middle Deltoid (SOURCE-25)

    • Vascular QSS - compression of the Posterior Humeral Circumflex Artery is likely to result in signs of acute ischemia including Pain , pallor (pale skin) or absent pulses, thrombosis or embolism (appearing bluish/ purple due to a insufficient oxygen) of The Hand and Fingers (SOURCE-23+24+25)

  • Direct injury of Nerve to Teres Minor - boasts similar symptoms to Axillary Nerve compression at the QSS; however, they are isolated to the Teres Minor (SOURCE-23)

Restriction

Teres Minor hypertonicity has the capacity to affect both the Humerus and Scapula :

Entrapment Site

The Teres Minor forms the proximal border of the Quadrilateral Space which is a known entrapment site for the Axillary Nerve that courses through it.

Fascia

In terms of Fascia l connections, the Teres Minor is included in the following:

A restriction at any point along the line/ chain could result in Pain or dysfunction of the Teres Minor.

Referred Pain

The accumulation of myofascial trigger points or Inflammation within the Teres Minor may result in Referred Pain . Pain is often intensely perceived in the Posterior Deltoid and may diffusely extend the posterolateral upper arm (SOURCE-8).


Pathology

Teres Minor dysfunction may be a predisposing factor to the following pathologies or vice versa:

Subacromial Impingement - Rotator Cuff pathology/ insufficiency can notably reduce the Subacromial Space to predispose impingement (SOURCE-5+29+30). Additionally, insufficent action from the Rotator Cuff may cause abnormal arthokinematics at the Glenohumeral Joint or Scapulothoracic Joint which may result in secondary impingement. Chronic impingement predisposes further Rotator Cuff pathologies such as Tendinopathy and/or tear .

Adhesive Capsulitis - Rotator Cuff pathology is considered a major intrinsic predisposing factor for secondary Frozen Shoulder (SOURCE-31). In the initialInflammatory Stage, shoulder motion becomes restricted despite full Rotator Cuff strength (SOURCE-31+32). Often the primary function of the Teres Minor ( GH Joint - External Rotation ) is the first range of motion to become restricted, occuring as early as theInflammatory Stage(SOURCE-32+33).

Glenohumeral Instability - shares a bidirectional relationship with Rotator Cuff pathology. Insufficiency of the cuff is associated with recurrence of unstable events (SOURCE-34). Conversely, instability may predispose Rotator Cuff injury as it disturbs its length-tension relationships, leading to excessive strain or overuse. Weakness in the Teres Minor may cause instability at the Glenohumeral Joint (SOURCE-35).

Axillary Nerve Compression - as described underPathomechanics.


Assessment

Observation

The following observations may be visible with Teres Minor dysfunction:

Range of Motion

In terms of Range of Motion assessment, disturbance of the following ranges may be indicative of Teres Minor pathology:

Orthopaedic Testing

Several Shoulder - Special Tests can be used to evaluate the integrity of the Teres Minor:

Strength Testing

Manual Muscle Testing of the Teres Minor can be performed to evaluate relative strength prone against gravity or seated without gravity (SOURCE-20). This is the same test used to evaluate the relative strength of the Infraspinatus and compensation from the Posterior Deltoid is common (SOURCE-20):

As the Teres Minor is relatively more active during GH Joint - External Rotation with the arm in 90º GH Joint - Abduction , a relative reduction in strength when compared to External Rotation in neutral may implicate the Teres Minor (SOURCE-18).

Palpation

The Teres Minor is the most distal Rotator Cuff palpable from the posterior between the Lateral Border of the Scapula and the Humerus . Differentiation between Teres Minor and its distal counterpart - Teres Major can be done through the use of rotation:

On its proximal border, Teres Minor neighbours Infraspinatus .

Neurological

Relevant neurological assessments for the Teres Minor focus primarily on its motor and sensory innervation from C5 and C6 Nerve Roots (SOURCE-22):

Imaging

As imaging findings alone do not consistently correlate with a patients symptoms and findings are often identified in asymptomatic shoulders, they should be complimented by physical examination before reaching a diagnosis and establishing a treatment protocol (SOURCE-9).

Radiographs (X-Rays)- generally the first line of imaging, used to determine presence of Acromial morphology or other related abnormalities such as Subchondral Cysts or a “notch” on the Greater Tuberosity or ligamentous calcification which may predispose impingement (SOURCE-10). X-Rays are also a reliable measure of theAcromiohumeral Interval, which quantifies the extent of impingement through determining the shortest distances between the inferior cortex of the Acromion and the peak of the Humeral Head (SOURCE-11). A distance of 7-14mm is considered normal, ≤ 7mm indicative of a large Rotator Cuff Tear and a distance smaller than 6mm indicates a chronic and complete tear of the Infraspinatus (SOURCE-11). The following views may be relevant (SOURCE-10+11+12+13+14):

  • AP view in the Scapula plane - also known asGrashey view, provides a (~20%) higher detection rate when compared to a conventional AP for the following conditions:

  • Outlet view - reveals morphology of the Acromion, including bony spurs as well as ligamentous calcification and other causes of impingement

  • Axillary view - evaluates for Os Acromiale and rules out Dislocation in cases of trauma

When X-Ray findings are unremarkable, CT Scans and MRI’s may be indicated (SOURCE-14).

Ultrasonography (Ultrasound)- an accessible imaging modality with dynamic, real-time capabilities for the evaluation of Rotator Cuff pathology and Subacromial Impingement via certain metrics (SOURCE-9+10+15):

  • Rotator Cuff Pathology

    • “focal heterogenous hypoechogenicity”, or a localised portion of the tendon that has a dark and abnormal appearance, indicates the presence of a Rotator Cuff Tear . This may result from accumulated fluid within the cuff surface or its substance. Linear appearing echogenicity within the substance with or without muscle atrophy may also suggest a tear . A complete non-echogenic (black) gap extending the thickness of the tendon indicates a full tear, while in partial tears attachment is still visible

    • a decrease in tendon thickness was associated with Subacromial Impingement which is indicative of degenerative changes associated with chronicity

  • Subacromial Impingement

    • Bursa - the thickening of associated bursa as seen in Subacromial Bursitis is indicative of Subacromial Impingement. Similarly, an increased width of the Subdeltoid Bursa may be indicative of impingement. This Inflammation is visualised as an increase in anechoic fluid within the bursa

    • Subacromial Space - like other imaging modailities, the Acromiohumeral Inverval may be established with Ultrasounds to quantify impingement. A side-to-side differential of <2.1mm was considered normal.

AStandard I (transverse plane) Viewtaken approximately 15mm lateral of the Long Head of Biceps may be used to evaluate the rotator cuff, although this distance is subject to anatomical variation (SOURCE-15). AStandard II (longitudinal plane) Viewmay be used to determine the Acromiohumeral Interval with the Humerus neutrally rotated (SOURCE-15). Other views that may be relevant include Standard Auxiliary Views I, II and III (SOURCE-15). A downfall of this imaging modality is that accuracy is clinician dependent (SOURCE-15).

Magnetic Resonance Imaging MRI- can be used to evaluate the integrity of the Rotator Cuff , the presence of concomitant injuries such as Subacromial Bursitis or SLAP Lesions or associated morphologies (SOURCE-9+10+16). The following findings may be indicative of Rotator Cuff pathology (SOURCE-10):

  • T1-weighted images - an increased signal without tendon discontinuity indicates a partial- tear . On T1 and proton-density images an increased signal and loss of anatomic definition suggests Tendinitis

  • T2-weighted images - a signal increase with intra-tendinous focal defect suggests partial- tear . Conversely, Tendinitis may have moderate or decreased signal

Computed Tomography (CT) Scan- akin to MR-arthrography, used most often for the evaluation of Cartilage or the Glenoid Labrum (SOURCE-9). Typically reserved as a complement to other imaging modalities for the assessment of bony changes or when MRI’s are contraindicated (SOURCE-9).


Treatment

Stretching

The following Stretching techniques may be used to restore length in the Teres Minor:

Strengthening

Early Phase:

Mid-Phase:

Late-Phase:

Myofascial Release

The Teres Minor can be treated directly or along the Fascial Lines / Myofascial Chains they belong to, particularly when hypertonicity is identified.

Practitioner Guided- with patient side-lying, longitudinal glides may be applied in the direction of restriction, usually towards the axilla. Pinching either muscle between the Thumb and Fingers , a “pin and stretch” type effect may be applied with the addition of GH Joint - Abduction . Transverse Frictions may also be applied at sites of adhesion.

Self-Guided:

  • Ball Release - lying supine with arm raised overhead on a trigger ball placed under the lateral surface of the Scapula , near the Teres Minor Scapula attachment

Dry Needling

Dry Needling of the Teres Minor is often indicated and done in a fashion similar to that of the Infraspinatus and Teres Major (SOURCE-19). The following lists key considerations when dry needling the Teres Minor (SOURCE-19):Starting Position:

  • Patient is preferably prone with their arm in 90º GH Joint - Abduction as to have their lower arm hanging over the edge of the table

Procedure:

  • Typically 30-40mm needles

  • Needle is inserted at a shallow angle and directed at a superior and lateral angle to follow the direction of the fibres towards their insertion

Precautions:

  • The Lungs - Needles are inserted at a shallow angle and away from the Thorax . Risk of Pneumothorax can be mitigated further using a pincer grip and needling between the fingers


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