thoracic outlet syndrome nate shin

7/28/2019 Thoracic Outlet Syndrome Nate Shin

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Thoracic Outlet Syndrome

by Nate Shin, Class of 2012

The website gives basic information about Thoracic Outlet Syndrome. A more in-depth

understanding of this disorder can be found with links to "Additional Web Based Resources"and "Footnotes" section below. Enjoy!

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Table of Contents

I. Description

II. Anatomy:

III. Indications:

IV. Incidence/ Prevalence:

V. Clinical Presentation

VI. Potential Etiologies:

VII. Diagnostic Tests:

VIII. Evaluation/Special Orthopedic Tests:

IX. Conservative Treatment:

X. Surgery & post-op treatment:

XI. Modalities:

XII. Additional Web Based Resources:

I. Description

Here is a brief video explaining this condition:

Thoracic Outlet Syndrome is an entrapment disorder that occurs inside the "thoracic

outlet" which is the space between the collarbone and the first rib. There are many nerves and

blood vessels and other structures that course through this area - usually between the scalene

muscles down to the inferior border of the axilla - and can become compressed and cause

symptoms. There are three types of TOS: neurogenic, vascular, and nonspecific. Depending

on which structures are compressed, this will cause numbness or tingling down the arm,

hand, and fingers, and/or pain into the neck and shoulder, among a variety of symptoms.

Usually, elevating the arms can make these symptoms worse.1,2

II. Anatomy:
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There are many bones, muscles, nerves, and blood vessels that course through the thoracic

outlet region. However, the structures that are most often affected in this disorder include the

clavicle, 1st rib, scalene muscles (anterior and middle scalene), pectoralis minor, the

subclavian artery and vein, and the upper and lower brachial plexus.1


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III. Indications:

Conceptually, TOS seems like a simple disorder, but it may be hard to tell whether a patient'ssymptoms indicate TOS. The presentation of it is variable depending on which part of the

brachial plexus or which part of the artery or vein is involved. In 98% of cases, the symptoms

are neurologic. 15% of these patients may have some concomitant arterial symptoms but

these arterial symptoms rarely occur alone. Most people report paresthesias (tingling or

prickling), pain in the arm, and paresis (muscular weakness caused by nerve damage).3

For neurological symptoms, if the upper plexus is involved (C5 to C7), pain is reported in the

neck and this may radiate into the face (sometimes with ear pain) and anterior chest, as well

as over the scapula. Symptoms can also go into the lateral aspect of the forearm into the hand.

If the lower plexus is involved (C7 to T1), pain and numbness occur in the posterior neck and

shoulder, medial arm and forearm, and into the ulnar innervated digits of the hand. Muscles

that are innervated by these nerves usually show some atrophy and weakness as well.1


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Vascular symptoms usually present with coldness or edema in the hand or arm, Raynaud's

phenomenon (cyanosis), fatigue and superficial vein distention in the hand. But again,

vascular symptoms are rare with this condition.1

IV. Incidence/ Prevalence:


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In the United States, because of the difficulty and the inaccuracy in diagnosing this condition,

the statistics in this area of incidence and prevalence is lacking in general health

organizations as well as the literature. It is known that this condition is more prevalent in

occupations that involve bad postures of the neck and continuous use of shoulders in

overhead activities. This includes secretaries, cashiers, machine operators, surgeons, and

truck drivers. There is no increased incidence in athletes.4

There are some reports that say that the prevalence is about 23% of soft tissue injuries of the

cervical spine. However, TOS is often misdiagnosed or overlooked, especially in the

emergency department. The incidence of neurogenic or vascular TOS is considered rare with

only one case per million population that is estimated for neurogenic TOS. In adults younger

than 40 years, some believe that TOS is the most common cause of acute arterial occlusion in

the upper limbs.4

In terms of age, this TOS occurs from the 2nd to the 8th decade with a peak in the 4th decade.

In the younger age group, there is a greater likelihood for anatomic or structural

abnormalities, such as an extra rib or fibrous bands.4 Females are diagnosed with thiscondition more often than males, with some reports saying it is a 9:1 female to male ratio

with this condition. This is attributed to the difference in the shape of the chest wall. In

addition, having large breasts can add to the anterior forces on the chest leading to drooped

shoulder posturing and further inhibiting the thoracic outlet.5

V. Clinical Presentation

The clinical presentation of typical TOS patients are:6

Those with enlarged scalene muscles due to repetitive work or sporting activities:swimmers, weight-lifters and others. Also people doing lifting of objects regularly at

work.

Young people with droopy shoulders and doing repetitive arm motions: e.g.musicians.

Scar tissue formation after collar bone or first rib fractures. Postural problems: dropping shoulders causing traction on the brachial plexus or short

stocky necks with soft tissue compressing the thoracic outlet.

A few of the symptoms that would make a physical therapist suspect this condition in any

patient would be:6

Shoulder pain: often over the AC joint or biceps area. Not uncommonly over the backof the upper arm. A continuous burning, lame feeling in the shoulder and down the

arm.


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Tingling (pins and needles) may be felt down the arm and into the hand and oftenparticularly into the little and ring fingers. There may be loss of control of the hand

with dropping objects.

The pain is often present at rest eg. when driving or simply sitting watching TV etc. The pain may radiate into the neck, the trapezius muscles, the shoulder blade (with a

burning character), jaw, the head and even chest area.

Traction downwards on the arm eg. when carrying shopping bags may aggravate thesensation down the shoulder and arm.

Pain and discomfort is often present following activities and not only during theactivitieseg. after swimming, throwing, etc.

Overhead activities as doing ones hair, hanging up washing, etc., may cause a feelingof fatigue and burning in the arm, having to bring the arm down because the overhead

position cannot be sustained.

VI. Potential Etiologies:

Common causes of thoracic outlet syndrome include physical trauma from a car accident,

repetitive injuries from job- or sports-related activities, and certain anatomical defects, such

as having an extra rib.

Acute neck trauma: Motor vehicle accidents (MVA) are highly associated withwhiplash injuries, which is the most common mechanism causing neurogenic TOS. In

a study by Sanders and Haug, more than half of the patients with neurogenic TOS

developed their symptoms from an MVA. This includes the neurologic symptoms

mentioned above, including pain in the neck and arms, as well as paresthesia in the

hands. This can be attributed to scarring of the scalene muscles after hyperextension

neck injuries, which can then compress the brachial plexus.7,8Trauma can also cause

shifting of structures in the thoracic outlet area that can lead to symptoms. Sometimes

the clavicle is fractured and can compress directly on structures.


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Repetitive stress and posture: Another likely cause is deemed to be mechanical withrepetitive stress being a factor, especially in the workplace. This includes people who

work at keyboards, telephones, assembly lines, or at desks for long periods of time.

Small trauma to the neck muscles occur by frequently turning the neck back and

forth.7 Poor posture can also cause muscle imbalances. Often, this is seen as forwardhead, droopy shoulders, and collapsed chest, which allows the thoracic outlet to

narrow and compress the neural structures.4
http://morphopedics.wdfiles.com/local--files/thoracic-outlet-syndrome/TOSposture.jpghttp://morphopedics.wdfiles.com/local--files/thoracic-outlet-syndrome/TOSposture.jpg


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Anatomic predispositions: Oftentimes, these "predispositions" are congenital such asbands and ligaments that are abnormally tight connecting the spine to the rib. Some

people have a cervical rib, which is an extra rib located above the first rib.7 However,

a study showed that in 80% of patients with cervical ribs, symptoms did not develop

until after a neck injury occurred, suggesting that these anatomic variations are indeed

predisposing factors and not causative factors.9

Another predisposition could be thescalene triangle (anterior and middle scalene muscles). In a study by Sanders and

Roos, anatomic observations of these variations were made in cadavers and compared

with similar observations on patients with TOS during surgery. Patients with TOS had

more nerve roots of the brachial plexus emerging from the apex of the triangle,

interdigitating fibers that put stress on the nerve roots, adherence of nerves to the

anterior and middle scalene muscles, and narrower triangles.10

VII. Diagnostic Tests:


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Different tests are used to elicit symptoms of TOS with positions that would compress thenerves within the anterior scalene muscle. A "positive test" for tests such as Adsons or Allens

would result in the peripheral radial pulse disappearing once the patient was put into the

proper test position. These tests, however, have a high false-positive response and the

disappearance of the peripheral pulse does not necessarily mean that TOS exists. Adson's

maneuverappears among the most effective (shown in picture above).1

Other studies show the most reliable test for TOS is the elevated arm stress test, (EAST)

described by Roos. It is performed by having the patient put both arms in the 90 abduction

external rotation position, with the shoulders and elbows in the frontal plane of the chest. The

patient is then instructed to open and close the hands slowly over a 3-minute period.

Normally the patient can perform this stress test for 3 minutes with only forearm musclefatigue and minimal distress. In those with an outlet syndrome, the test reproduces the usual

TOS symptoms: gradual increase of pain in the neck and shoulder, aching progressing down

the arm, and paresthesias developing in the forearm and fingers.3

Other various tests have also shown to compress the neural structures with certain positions

as well such as the Allen's, Wright's, Halsted's, costoclavicular, and provacative elevation

tests.1


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A combination of tests can be used and the sensitivity and specificity of the Adson's test

improves when used in combination with the hyperabduction test, the Wright's test or the

Roos test. This is shown in the table below.11

One thing that cannot be forgotten are tests to rule out other conditions and injuries. This

includes ROM and strength tests for neck, shoulder, and upper extremities; blood pressure of

both sides; carpal tunnel syndrome; muscle spasm; cervical disc syndrome, as well as upper

limb tension tests (ULTT 1, 2a, 2b, 3). 3 Radiographic tests to identify bony abnormalities

and electrophysiologic [nerve conduction velocity (NCV)] tests would also allow the

examiner to pinpoint the lesion in the presence of neuropathy.1

The problems with diagnosis:

VIII. Evaluation/Special Orthopedic Tests:

The PT will often do special tests to support or negate their hypothesis. The three most

common special orthopedic tests are the Roos, Adsons, and Allens tests. The directions are

stated and pictures shown in the videos below:


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IX. Conservative Treatment:

The initial treatment for TOS is always conservative when presenting symptoms are mild to

moderate in severity. Postural and breathing exercises and gentle stretching are usually the

conservative treatment used by people that have this condition. This is followed by

strengthening exercises for shoulder girdle muscles including the trapezius, levator scapulae,

and rhomboids. Overhead exercises are avoided initially.1

Conservative treatment focuses on decreasing extrinsic pressure and reducing intrinsic

irritation. By reducing inflammation in the thoracic outlet and shortening or lengthening the

surrounding musculature for proper balance, pressure against the neurovascular bundle is

decreased. The following are different conservative treatments for TOS:12

Pain and edema control:o Anti-inflammatory and pain medication, muscle relaxants, and therapeutic

modalities (heat, transcutaneous electrical nerve stimulation [TENS],

phonophoresis)

o Trigger point injections with an anesthetic and steroid solutiono Edema control would include edema gloves, compressive garments and

sleeves, elevation, active range of motion, and retrograde massage.

Education:o Posture:

Bring shoulders back to a relaxed but retracted position; head shouldglide back automatically when shoulders are in correct position, weightshould be distributed equally on both feet and low back should retain

its normal lordosis. Patient may need to look in a mirror at front and

side views. The patient can attempt a rigid military stance and then

relax the position to improve comfort and compliance. Proper posture

should be maintained when sitting, standing, or walking.

o Ergonomics: One example is sitting at a desk. If the patient works at a computer the

chair height should be adjusted so that the patients feet rest solidly on

the floor with hips and knees at a 90 angle. The spine should be

supported especially at the lower back, keeping the natural curve

intact. The computer monitor ideally should be positioned so that thescreen is slightly below eye level and angled upward to prevent neck

hyperextension. The patient should be able to look at the screen

comfortably without turning or straining of the neck. If the patient

stands while using the computer, one foot at a time can be propped

onto a small stool to keep proper low back posture and prevent

slouching.

o Relaxation: Deep breathing, mild aerobic, or contractrelax exercises are important

in preventing muscle guarding around the shoulder girdle

Hot showers, heating pads, and massages


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Exercises: This involves relaxing the shoulder girdle and upper trapezius musculature,stretching the scalene and pectoral muscles, and strengthening the cervical extensors,

scapular adductors, and shoulder retractors.

o Neck: chin tucks; neck side bends, rotation, flexion stretches; neck half circleso Shoulder: pendulum exercises; shoulder shrugs; shoulder circles; elbow

pinches; doorway/corner stretch; high swings; side wingso Nerve gliding exercises: Nerve gliding patterns for the thoracic outlet include

motions of the neck and entire upper extremity. For example, the neck bends

to the right while the right elbow extends and the wrist flexes and then the

neck side bends to the left shoulder while the right elbow flexes and the wrist

extends. The basic concept is that while pulling on the nerve in one direction,

tension in the other direction is relieved, thus gliding the nerve

o Manual therapy and soft tissue techniques: Manipulation of the scapula and thoracic outlet area is believed to be

beneficial. This includes sternoclavicular joint, scapula, and the first

rib articulations, acromioclavicular mobilization, and thoracic

articulation mobilization Deep fascial and trigger point massage release especially of the

trapezius and rhomboid muscles

Feldenkrais method of body awareness therapy

X. Surgery & post-op treatment:

Surgical management of TOS is reserved for cases that are unmanageable to postural and

exercise correction and those with vascular compromise. As with any surgery, there areinherent risks associated with TOS surgery and appropriate in-depth discussions with a

surgeon should be undertaken prior to selecting this last resort treatment.

Different surgical procedures:1

Scalenotomy: muscle is detached from the first rib Scalenectomy: removal of the scalene muscle Clavicle resection: indicated primarily when the clavicle is damaged Pectoralis minor release First rib resection Cervical rib resection

When scalenectomy, with or without first rib resection, is the surgical approach used, its 5-

year success rate is about 70%.13

Most common anatomic approaches:1,2

Anterior supraclavicular approach: This approach repairs compressed blood vessels.Your surgeon makes an incision just under your neck to expose your brachial plexus

region. He or she then is able to look for signs of trauma or may discover fibrous

bands contributing to compression near your first (uppermost) rib and can repair any

compressed blood vessels.


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Transaxillary approach: In this surgery, your surgeon makes an incision in your chestto access the first rib, then removes a portion of the first rib to relieve compression.

The advantage of this type of surgery is that it gives the surgeon easy access to the

first rib without disturbing the nerves or blood vessels. But it also means the surgeon

has limited access to the area's nerves and vessels, and most fibrous bands and

cervical ribs that may be contributing to compression are hidden behind these nervesand blood vessels.

After surgery, 70% of cases have a good or excellent response using a supraclavicular or

transaxillary resection of the first rib. Improvement in pain symptoms ranges from 70% to

80%, some patients require occasional analgesics, and 10% note no improvement. In

individuals with signs and symptoms and electrophysiologic changes consistent with classic

TOS, no improvement in strength is noted when atrophy was present before surgery.14

However, a 4-year follow-up reported no significant difference in return to work or symptom

severity when the first rib was resected compared to a conservative, nonoperative approach.15

Post-Op Treatment:16

A general guideline for treatment after surgery for thoracic outlet syndrome

Postoperative Day 1 (week 1): gentle range of motion, active and active-assistedrange of motion; drain removal at approximately 35 days

Postoperative Day 8 (week 2): suture removal; continue gliding exercises for neck andupper extremity

Postoperative Day 15 (week 3): scar massage, scar desensitization Postoperative Day 22 (week 4): phonophoresis to scar site, brachial plexus massage,

start strengthening exercises

Postoperative Day 29 (week 5): upgrade strengthening exercises Postoperative Day 36 (week 6): ergonomic training, work-simulated activities Postoperative Days 4383 (weeks 712): work hardening

XI. Modalities:

Modalities can play a key role in both conservative and post-operative treatments of TOS. It

is not used as a sole method of treatment but is often used in combination with othertreatments, such as postural and ergonomic education, stretching, strengthening, and nerve

gliding exercises.

For conservative treatment:12

A conservative routine is suggested to continue for 4-6 months before surgery is considered.

During this time, modalities are utilized mainly for pain control, edema control, and

relaxation.

Pain control: (in addition to anti-inflammatory and pain medication, musclerelaxants):

o Heat (before exercise and ice afterwards)


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o Transcutaneous electrical nerve stimulation (TENS)o Microcurrent and cranial electrotherapy stimulationo High voltage pulsed currento Phonophoresis (ultrasound)

Edema control: (in addition to edema gloves, compressive garments and sleeves,elevation, AROM, retrograde massage)

o Phonophoresis treatments (ultrasound with steroid gel)also potentially helpscontrol inflammation and scar contraction.

Relaxation: (in addition to deep-breathing, mild aerobic, or contract-relax exercises)o Heating pads, hot showers (cold temps should be avoided, can irritate TOS

symptoms)

For post-operative treatment:16

Postoperatively, there is more of an emphasis of modality use on wound care, edema control,

and scar management while also incorporating nerve gliding and ROM exercises.

Wound care:o Ice as tolerated for 10-minute periods, on and off for the first 3-4 days

Scar management (begins 24-48 hrs after sutures have been removed):o Phonophoresis with triamcinoline gel (0.3%) begins at 3 weeks over the scar

site and brachial plexus (can also extend to upper trapezius in the event muscle

tightness is noted)

Pain management:o TENS (pads can be placed along the injured nerve pathways of the injured

extremity or over upper trapezius)

o Heat is recommended before exercises (after initial inflammatory period) andice after the exercise program

XII. Additional Web Based Resources:

A series of links to appropriate web sites to learn more about this condition.

National Library of Medicine - National Institutes of Health - MedlinePlus Mayo Clinic Intraspec.ca - Thoracic Outlet Syndrome

Footnotes

1. Goodman CC, Fuller K.Pathology: Implications for the Physical Therapist. 3rd ed. St.

Louis, MO: Saunders Elsevier; 2009.

2. Mayo Clinic staff. Thoracic Outlet Syndrome Page.

http://www.mayoclinic.com/print/thoracic-outlet-

syndrome/DS00800/DSECTION=all&METHOD=print. Updated November 6, 2010.

Accessed November 29, 2010.
http://www.nlm.nih.gov/medlineplus/thoracicoutletsyndrome.html#cat3http://www.nlm.nih.gov/medlineplus/thoracicoutletsyndrome.html#cat3http://www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800http://www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800http://intraspec.ca/tos.php#Epidemiologyhttp://intraspec.ca/tos.php#Epidemiologyhttp://www.mayoclinic.com/print/thoracic-outlet-syndrome/DS00800/DSECTION=all&METHOD=printhttp://www.mayoclinic.com/print/thoracic-outlet-syndrome/DS00800/DSECTION=all&METHOD=printhttp://www.mayoclinic.com/print/thoracic-outlet-syndrome/DS00800/DSECTION=all&METHOD=printhttp://www.mayoclinic.com/print/thoracic-outlet-syndrome/DS00800/DSECTION=all&METHOD=printhttp://www.mayoclinic.com/print/thoracic-outlet-syndrome/DS00800/DSECTION=all&METHOD=printhttp://intraspec.ca/tos.php#Epidemiologyhttp://www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800http://www.nlm.nih.gov/medlineplus/thoracicoutletsyndrome.html#cat3


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3. Brantigan CO, Roos DB. Diagnosing thoracic outlet syndrome.Hand Clin. 2004;20:27-36.

4. Sucher BM. Thoracic Outlet Syndrome Page.

http://emedicine.medscape.com/article/316715-overview. Updated July 1, 2009. Accessed

December 3, 2010.

5. Al-Shekhlee A, Katirji B. Spinal accessory neuropathy, droopy shoulder, and thoracic

outlet syndrome.Muscle Nerve. 2003;28(3):383-385.6. Harris DG. Shoulder Problems/Thoracic Outlet Syndrome.

http://www.shoulderinstitute.co.za/thoracic_outlet_syndrome.php. Accessed December 1,

2010.

7. Sanders RJ, Hammond SL. Etiology and pathology.Hand Clin. 2004;20:23-26.

8. Sanders RJ, Haug CE. Thoracic outlet syndrome: a common sequela of neck injuries.

Philadelphia, PA: JB Lippincott; 1991. p. 26.

9. Sanders RJ, Hammond SL. The significance and management of cervical ribs and

anomalous first ribs.J Vasc Surg. 2002;36:5156.

10. Sanders RJ, Roos DB. The surgical anatomy of the scalene triangle. Contemp Surg.

1989;35:1116.

11. Gillard J, Perez-Cousin M, Hachulla E, et al. Diagnosing thoracic outlet syndrome.Contribution of provocative tests, ultrasonography, electrophysiology, and helical computed

tomography in 48 patients.J Bone Spine. 2001;68:416-424.

12. Crosby CA, Wehbe MA. Conservative treatment for thoracic outlet syndrome.Hand Clin.

2004;20:43-49.

13. Sanders RJ, Hammond SL. Supraclavicular first rib resection and total scalenectomy.

Techniques and results.Hand Clin. 2004;20:61-70.

14. Colli BO, Carlotti CG, Assirati JA, et al. Neurogenic thoracic outlet syndromes. A

comparison of true and nonspecific syndromes after surgical treatment. Surg Neurol.

2006;65:262-272.

15. Landry G, Moneta GL, Taylor LM, et al. Long-term outcome of neurogenic thoracic

outlet syndrome in surgically and conservatively treated patients.J Vasc Surg. 2001;33:312-

314.

16. Wishchuk JR, Dougherty CR. Therapy after thoracic outlet release.Hand Clin.

2004;20:87-90.
http://emedicine.medscape.com/article/316715-overviewhttp://emedicine.medscape.com/article/316715-overviewhttp://www.shoulderinstitute.co.za/thoracic_outlet_syndrome.phphttp://www.shoulderinstitute.co.za/thoracic_outlet_syndrome.phphttp://www.shoulderinstitute.co.za/thoracic_outlet_syndrome.phphttp://emedicine.medscape.com/article/316715-overview

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