Thoracic Outlet Syndrome (TOS), first described in 1821 by Sir Astley Cooper. It occurs in women more than men (3:1) and most commonly between the ages of 10 and 50 years of age. (TOS) is a group of distinct disorders producing signs and symptoms attributed to compression of the neurovascular bundle, which consists of the brachial plexus (C5-T1) and the subclavian artery and vein in the thoracic outlet region. (The thoracic outlet is bounded by several structures: the anterior and middle scalene muscles, the first rib, the clavicle, and, at a lower point, by the tendon of the pectoralis minor muscle.) TOS can be further divided into 3 subgroups; neurologic, venous and arteriole.
Clinical signs and symptoms of TOS usually include pain in the neck and shoulder area and numbness and weakness in the arm/hand. Other names typically used to describe the cause or location of the symptoms include fractured clavicle syndrome, pneumatic hammer syndrome, nocturnal paresthetic brachialgia, rucksack paralysis, cervicobrachial neurovascular compression syndrome, and shoulder-hand syndrome. While descriptive, most health care providers use the terms scalenus anticus syndrome, costoclavicular syndrome, and pectoralis minor syndrome to describe the three primary anatomic areas most affected in thoracic outlet syndrome. Thrombos (Paget Schroetter syndrome in subclavian vein) and resulting complications can also occur secondary to stasis.
(The brachial plexus is the network of motor and sensory nerves which innervate the arm, the hand, and the region of the shoulder girdle. The vascular component of the bundle, the subclavian artery [posterior to anterior scalene] and vein [anterior to anterior scalene] transport blood to and from the arm, the hand, the shoulder girdle and the regions of the neck and head.)
Causes
It is most often the result of poor, repetitious or strenuous postures producing constant muscle tension in the shoulder girdle. Static postures such as those sustained by assembly line workers, cash register operators, students or, computer operators often result in a drooping shoulder and forward head posture. Carrying heavy loads, briefcases and shoulder bags can also lead to neurovascular compression. Occupations or sports which require repetitive over head arm movements can also produce symptoms of compression. Thoracic outlet syndrome can also result from trauma or congenital anomalies (Some people are born with an extra rib right above the first rib, called a cervical rib).
As the brachial plexus and subclavian vessels pass through the thoracic outlet, there is potential for both static and dynamic compression and/or compromise. Since the thoracic outlet is a closed space, any intrusion or swelling such as from a fractured clavicle, hypertrophied or spasming muscle or tumor can lead to static compression of the structures that pass through that space. Dynamic movements, such as holding the arm overhead and backward (hyperabduction), will put further compression on the enclosed structures and bring on symptoms, especially if the space is already compromised because of tight muscles. Even breathing can add compression to the thoracic outlet. Breathing is normally begun with the diaphragm, but in paradoxical or chest breathing the patient starts by elevating the upper ribs with the scalene muscles and this tightens the thoracic outlet.
Direct Causes
Anterior scalene (C3, 4, 5, 6 to first rib) tightness or hypertrophy will cause compression of the interscalene space between the anterior and middle scalene muscles, probable causes are poor posture or from nerve root irritation, spondylosis or facet joint inflammation leading to muscle spasm.
Costoclavicular approximation will compress the space between the clavicle, the first rib and the muscular and ligamentous structures in the area, probably from postural deficiencies or carrying heavy objects, or subclavius muscle hypertrophy.
Pectoralis minor (3rd, 4th, and 5th ribs to coracoid process) tightness causes narrowing of the space under the coracoid process which may result from poor posture or repetitive movements of the arms above the head.
Signs and Symptoms
Thoracic outlet syndrome has taken on negative connotations because of poor surgical results or because it has often been employed as a “wastebasket” term when the treating clinician is short on a diagnosis and unable to explain the patient's complaints. This has resulted in much controversy and disagreement among professionals along with confusion and distrust among claims examiners and patients. A variety of other conditions will produce signs/symptoms that may be confused with TOS including carpal tunnel syndrome, cervical spine disease with nerve root compression, tumors of the spinal cord or brachial plexus, Pancoast tumor, Raynaud's disease, stretch injuries to the brachial plexus, myofascial pain syndrome, other peripheral nerve entrapments of the upper extremity (cubital tunnel) as well as a variety of other neuromuscular disorders.
Vascular symptoms
Swelling or puffiness in the arm or hand
Bluish discoloration of the hand
Feeling of heaviness in the arm or hand
Pulsating lump above the clavicle
Deep, boring toothache-like pain in the neck and shoulder region which seems to increase at night
Easily fatigued arms and hands
Superficial vein distention in the hand
Neurological symptoms
Paresthesia along the inside forearm and the palm (C8, T1 dermatome)
Muscle weakness and atrophy of the gripping muscles (long finger flexors) and small muscles of the hand (thenar and intrinsics)
Difficulty with fine motor tasks of the hand
Cramps of the muscles on the inner forearm (long finger flexors)
Pain in the arm and hand
Tingling and numbness in the neck, shoulder region, arm and hand
Testing for TOS
Electromyography (EMG) and Nerve conduction studies, can give information about the health of the nerve.
CT or CAT scan will give relationship between sort tissue and bone. MRA (Magnetic Resonance Angiography), study of blood vessels and MRI may also be of some use.
Doppler study, is an Ultrasound of the veins.
Venography or arteriography may be the best way to diagnose TOS, a study of the veins done with dye and X-rays.
Physical tests:
Thoracic outlet compression tests must be interpreted carefully, since even asymptomatic individuals can develop arm numbness, tingling, pain, and diminution of the wrist pulse with these maneuvers. It is a challenge to the clinician to determine the significance of findings on examination in light of the entire clinical picture, including consideration of non-organic, psychosocial factors of disability and dysfunction. Besides the tests described, assessment of breathing technique, overall fitness, asymmetries, temperature and color of skin, as well as other tests of the neck and shoulder should be considered.
“Adson's Maneuver” or Scalene Maneuver
(This test has low Sensitivity and Specificity: Sensitivity is the percentage of subjects with the condition who also show a positive result on the test. It determines how "sensitive" (accurate) the test is at determining the condition when it is present. Specificity is the percentage of subjects without the condition who show a negative result on the test. It determines whether the test can show if someone doesn't have the condition.)
The examiner locates the radial pulse. The patient rotates their head toward the tested arm and lets the head tilt backwards (extends the neck) while the examiner extends the arm. A positive test is indicated by a disappearance of the pulse. {Testing Routine: Apply firm pressure to lower scalene bellies, near first rib for 30 seconds. Referred pain pattern is to anterior chest, neck, or interscapula region. Place involved arm in shoulder extension with some external rotation and palpate radial pulse. Neck rotation to same side, with extension, hold 30 seconds, assisted depression of shoulder clavicle, hold 30 seconds, ask patient to elevate ribs by taking a deep breath and holding 10 seconds.}
Allen Test
The examiner flexes the patient's elbow to 90 degrees while the shoulder is abducted and extended horizontally and rotated laterally. The patient is asked to turn their head away from the tested arm. The radial pulse is palpated and if it disappears as the patient's head is rotated the test is considered positive.
Hallstead Test
This test is like the Adson's maneuver, but hear turned to opposite side.
Costoclavicular Maneuver or “Eden's Test”
The examiner locates the radial pulse and draws the patient's shoulder down and back into extension with elbow extended, as the patient lifts their chest in an exaggerated "at attention or military" posture. A deep breath can be taken and held for 10 seconds. A positive test is indicated by an absence of a pulse. This test is particularly effective in patients who complain of symptoms while wearing a backpack or a heavy jacket.
Hands-up or “Roos Test”
The patient brings their arms up to 90° with elbows slightly behind the head, and flexed to 90°. The patient then opens and closes their hands slowly for 3 minutes. A positive test is indicated by pain, heaviness or profound arm weakness or numbness and tingling of the hand, the number of repetitions can be used to monitor progress or compare left to right.
Bakody maneuver
The patient places palm of involved hand on top of head with elbow at same height. This position can increase symptoms.
Overhead Test
Patient in Bakody position and asked to hold a 2-3 lb weight and repeatedly extend and flex the elbow, watch fro rapid fatigue and count repetitions.
Wright's Test (for pectoralis minor involvement)
Patient hyper-abducts arm above head to 180°, examiner palpates pulse and compares to uninvolved arm.
Provocative Elevation Test
This test is used on patients who already present with symptoms. The patient sits with arms across chest with hands on opposite shoulders and the examiner grasps the patient's elbows. The patient is passive as the shoulders are elevated forward and into full elevation. The position is held for 30 seconds or more. This activity is evidenced by increased pulse, skin color change (more pink) and increased hand temperature. Neurological signs go from numbness to pins and needles or tingling as well as some pain as blood flow to the nerve returns. Similar to what is felt after an arm "falls asleep" and circulation returns.
Treatment
Medication may be used to control pain, inflammation, and spasms.
NSAIDS, (Ibuprofen, Naproxen, Daypro) for pain and inflammation.
Anticonvulsants, (Neurontin) to manage nerve pain.
Muscle Relaxants, (Flexeril, Soma) to relax tight muscles.
Anti-depressants, (Prozac, Elavil, Paxil) to reduce pain and depression.
Thrombolysis (Streptokinase, Urokinase) to break down clots.
Anticoagulants ( Heparin, Coumadin) to prevent clots.
The objectives of treatment include: 1) relieve the compression of the nerves and blood vessels in the thoracic outlet region; 2) control and minimize pain and other symptoms to the greatest extent possible; and 3) improve the patient's overall quality of life.
Conservative treatment is usually the first-line approach and only a small number of patients require surgery. This usually includes Postural therapy, Muscle strengthening, Nerve gliding, Strengthening, Stretching, Massage, Chiropractic, Acupuncture, Movement therapies. Ultrasound, EMS, TENS, Light Therapy. Should symptoms persist over 3 or 4 months or if there is intractable pain, vascular loss or neuralgic loss then surgery should be considered. Surgery involves first rib resection and detachment and possible removal of anterior scalene muscle, venoplasty or stent placement. Compared with a non-surgical approach, patients receiving surgery had greater medical costs and have been found to be three to four times more likely to be work disabled. Surgery is consistent in relieving pain but muscle weakness and atrophy do not usually improve significantly.
Other Options for Treatment:
Injections: Trigger point , Botox, Cortisone, Stellate ganglion blocks.
Spinal cord or peripheral nerve stimulators. Medication pumps. Nerve Ablation.
PHYSICAL THERAPY
Initial treatment and management of TOS requires accurate evaluation of the peripheral nervous system, posture, joint mobility, strength, muscular imbalance, and co-ordination of cervical-scapular region. Evaluation of activities of daily living and the workplace environment is a must. Patients should be instructed in postural re-education in sitting, standing and sleeping, stretching exercises, diaphragmatic breathing, aerobic exercise, and strengthening exercises of the scapular stabilizers. It is essential to regain normal movement patterns in the cervical-scapular region with attention to posture and form. Emphasis may be placed on cardiovascular conditioning, the passage of time and weight loss if indicated. Patient education, compliance to an exercise program, and behavioral and ergonomic modification at home and work are critical to long-term successful conservative management.
Short-term modalities such as heat, cold, massage, ultrasound and electrical stimulation may reduce symptoms temporarily and through pain reduction allow treatment and stretching of the effected tissues. Instruction in avoiding postures or positions that aggravate symptoms: (drooping shoulders, sustained overhead activity, carrying heavy objects in the hand of the affected extremity, sleeping on the affected side). Biofeedback and/or relaxation training can be helpful in relaxing the involved musculature, improving diaphragmatic breathing, retraining skilled hand function, and improving postural awareness.
The fluid systems of our bodies require movement to maximize their efficiency. The pain of this condition will tend to inhibit motion, thereby decreasing the efficiency of the nutritional support. Treatment must address these systems and increase the efficiency of their flow.
Treatment involves training the patient to take control of there own problem. The exercises look easy but they involve a lot of practice to be done correctly. Part of each treatment requires that the patient demonstrate the exercises. If they have not been compliant with their exercises on their own it will usually be obvious. This need for patient accountability is a necessary step in their gaining control. Patients frequently enter therapy with emotional states that can be characterized as skeptical, discouraged and depressed. They will benefit from clear education about their condition with such this as visual analogies, empowering their intellect and helping them more clearly understand why they have the problem and what they need to do to resolve it. (The patient can be guided by seeing the solution to the problem as analogous to "opening the tunnel and draining the swamp.")
Patient's need to be continually assessed for their readiness and willingness to participate in treatment as those with non-physiologic or psychosocial issues or some with a sense of entitlement or anger appear to respond less well to treatment.
A few examples:
Stretching the back of the neck (upper trap).
Ipsilateral arm raised and elbow flexed, side bend head away and rotate away while pushing with hand or reach over head with opposite hand and sit on ipsilateral hand.
Stretching the chest.
Pectoralis stretch in doorway or corner, or butterfly stretch.
Scalene stretch.
Cervical extension and side bend away, use opposite arm to hold shoulder and first rib down.
Stretching the shoulder and the chest.
Wall / table slides or Triceps lowering chest stretch.
Mobilization of the first rib
Use a large bath towel and grasp it at opposite corners. Sling it across the shoulder of tightness and bring both ends across to the opposite hip or waist. With the arm on that side pull gently downward then release slowly.
Diaphragmatic breathing
Scaption exercise
Cervical retraction
To strengthen cervical longus coli muscles for cervical stabilization.
Cardiovascular exercise
At a target heart rate appropriate for the client.
Postural instruction
For sitting, standing, sleeping and performing functional activities.
