Thoracic Outlet Syndrome (TOS)

· the brachial plexus plus the C8 [the nerve root that runs between the C7-T1 segment of the cervical spine (neck) and the thoracic (chest) spine] and Tl [a nerve root from the thoracic spine] nerve roots and

· the subclavian artery and vein."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Brachial Plexus and C8 and T1 Nerve Roots

"The brachial plexus is the network of motor and sensory nerves which innervate

· the arm,

· the hand, and

· the region of the shoulder girdle."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Subclavian Artery and Vein

"The vascular [blood vessel] component of the bundle, the subclavian artery and vein transport blood to and from

· the arm,

· the hand,

· the shoulder girdle and

· the regions of the neck and head."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Bony, Ligamentous, and Muscular Obstacles

"The bony, ligamentous, and muscular obstacles all define the cervicoaxillary canal or the thoracic outlet and its course from the base of the neck to the axilla or armpit. Look at the scheme [see photo] of this region and it all becomes more easily understood."
NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Symptoms

Things to Consider

"It is important to understand that

· Presenting with the symptoms listed below in no way indicates a definitive diagnosis for thoracic outlet syndrome.

· Professionals understand the importance of coupling diagnostic testing skills with the patient’s report of what hurts and what doesn’t seem to be working properly.

· Don’t self diagnose! Neurologic and vascular symptoms can be indicative of more serious conditions."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Vascular Symptoms

1. "Swelling or puffiness in the arm or hand

2. Bluish discoloration of the hand

3. Feeling of heaviness in the arm or hand

4. Pulsating lump above the clavicle

5. Deep, boring toothache-like pain in the neck and shoulder region which seems to increase at night

6. Easily fatigued arms and hands

7. Superficial vein distention [enlarged veins on the surface] in the hand"

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Neurologic Symptoms

1. "Parasthesia [numbness or tingling] along the inside forearm and the palm (C8, T1 dermatome)

2. Muscle weakness and atrophy of the gripping muscles (long finger flexors) and small muscles of the hand (thenar and intrinsics)

3. Difficulty with fine motor tasks of the hand

4. Cramps of the muscles on the inner forearm (long finger flexors)

5. Pain in the arm and hand

6. Tingling and numbness in the neck, shoulder region, arm and hand"

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Causes

Physiological Causes

Physiological Causes: Compression of the Thoracic Outlet

"Compression occurs when the size and shape of the thoracic outlet is altered. The outlet can be altered by

· exercise,

· trauma,

· pregnancy,

· a congenital anomaly,

· an exostosis [overgrowth of normal bone],

· postural weakness or changes."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Physiological Causes: Component Syndromes

"Below is a list of the component syndromes which comprise thoracic outlet syndrome along with a brief description of each. Refer to the scheme [see photo] for questions about the gross anatomy of the region."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Physiological Causes: Component Syndromes: Anterior Scalene Tightness

"Compression of the interscalene space between the anterior and middle scalene muscles [see photo]--probably from

· nerve root irritation [when some structure puts pressure upon the nerve root],

· spondylosis [degeneration of the disc spaces between the vertebrae, commonly associated with osteoarthritis] or

· facet joint [any of the four projections that link one vertebra of the spine to an adjacent vertebra] inflammation [redness, warmth, swelling, and pain] of leading to muscle spasm."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Physiological Causes: Component Syndromes: Costoclavicular Approximation

"Compression in the space between

· the clavicle [collar bone],

· the first rib and

· the muscular and ligamentous structures in the area

--probably from postural deficiencies or carrying heavy objects."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Physiological Causes: Component Syndromes: Pectoralis Minor Tightness

"Compression beneath the tendon of the pectoralis minor under the coracoid process--may result from repetitive movements of the arms above the head (shoulder elevation and hyperabduction)."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Activities

Activities: Poor or Strenuous Posture, Trauma, Muscle Tension

"Thoracic outlet syndrome has been described as occurring in a diverse population. It is most often the result of poor or strenuous posture but can also result from trauma or constant muscle tension in the shoulder girdle."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Activities: Static Posture

"Static postures such as those sustained by assembly line workers, cash register operators, students of, for example, those who do needle work often result in a drooping shoulder and forward head posture. This position of the shoulders and head is also indicative of poor upper body posture. Middle aged and elderly women who suffer from osteoporosis often display this type of posture as a result of increased thoracic spinal kyphosis."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Activities: Carrying Heavy Loads

"Carrying heavy loads, briefcases and shoulder bags can also lead to neurovascular compression. Humans are not well adapted as beasts of burden and heavy loads hung form the shoulders and arms can stress the supporting structures of the shoulder girdle which is basically suspended by the clavicle and all of the component ligaments and muscles."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Activities: Repetitive Overhead Arm Movements

"Occupations which require repetitive over head arm movements can also produce symptoms of compression. Electricians, painters and plasterers may develop hyperabduction syndrome. Compression of the neurovascular structures also occurs in athletes who repetitively hyperabduct their arms. Swimmers, volleyball players, tennis players and baseball pitchers may suffer compression of the neurovascular structures as well. However, compression of these structures may be caused by stretching or microtrauma (small tears in muscle tissue) to the muscles which support the scapula."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Other Causes

"Some people are born with an extra rib right above the first rib. Since this intersection of nerves, vessels, muscles, bones and ligaments is already quite involved one can imagine what the presence of an extra rib in the region might do. A fibrous band extends from this cervical rib to the first rib causing an extra bend in the lower part of the brachial plexus which may produce a compression in this region."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Treatment

Things to Consider

"The first step to beginning any treatment begins with a trip to the doctor.

· Make a list of all of the symptoms which seem to be present even if the sensations are vague.

· Make a note of what activities and positions produce or alleviate the symptoms and

· the time of day when symptoms are worst.

· Also, note when the symptoms first appeared.

This list is important and should also include any questions one may have."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Diagnosis

"Due to overlapping in terms of symptoms it’s difficult to make a definitive diagnosis; this is why a list is so important. Certain diagnostic tests have been designed which are very useful for examination. These tests involve maneuvers of the arms and head and can help the practitioner by providing information as to the cause of the symptoms and help in designing an approach to treatment. These tests, accompanied by a thorough history help in ruling out other causes which may produce similar symptoms. These include Pancoast tumor, neurofibromas, cervical spondylosis, cervical disk herniation, carpal tunnel syndrome and cubital tunnel syndrome. Don’t forget to ask your practitioner about these conditions as well.

Here [on the linked page] are a few more commonly applied provocation tests used in the diagnosis of thoracic outlet syndrome. These tests may or may not momentarily reproduce symptoms but as was mentioned earlier are important in ruling out other causes which may produce similar symptoms."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

Conservative Treatment

"Once a diagnosis is decided, every effort is made for a conservative treatment approach. That means it won’t hurt. 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 is consistent in relieving pain but muscle weakness and atrophy do not usually improve significantly.

Conservative treatment usually includes

· local heat and

· a program which address

postural retraining,
shoulder strengthening and
stretching exercises.

The practitioner will create a treatment program specific to the presenting symptoms. Below [on the linked page] are a few self-stretching exercises.

· All of these exercises should be performed slowly and carefully.

· Each position is assumed smoothly to the point where a stretch is felt intensely but with no pain.

· There should be no bouncing in any of these positions.

· Hold the stretch for 30 seconds and then gently and slowly release it.

· Wait 10 seconds and repeat the stretch 3-5 times.

· If the stretches increase the symptoms do not continue."

"…These stretches are not cures. They may help in alleviating some of the symptoms of thoracic outlet syndrome but as with any exercise program one should always consult a physician before beginning particularly when symptoms persist for any length of time."

NISMAT: Physical Therapy Corner: Thoracic Outlet Syndrome

"An initial conservative approach to patients with thoracic outlet syndrome include the following measures:

1. Stretching and strengthening exercises of the shoulder and neck muscles

2. Weight loss relieves symptoms in obese patients

3. Anti-inflammatory medications to relieve pain

4. Changing positions and workstation, avoiding repetitive activities, postural exercise with frequent breaks (shoulder shrug exercise is an effective tool to relax the muscles around the thoracic outlet)."

eCureMe.com: Thoracic Outlet Syndrome

· Upper Extremity and Neck Flexibility: Additional Information: Shoulder Shrugs

Things to Consider

Compression of the Subclavian artery (part of the neurovascular bundle) might interfere with absorption of fat-soluble vitamins.

· Other Suggestions: Vitamins and Minerals: Fat-Soluble Vitamins: Absorption

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