Assessment and management of Thoracic outlet syndrome

1. Thoracic Outlet Syndrome

2. TOS is a collective term given for 6
syndromes:
i. Cervical rib syndrome
ii. Scalenus anticus syndrome
iii. Costoclavicular syndrome
iv. Hyperabduction syndrome
v. Pectoralis minor syndrome
vi. First thoracic rib syndrome

3. Causes:
 This syndrome is caused due by compression of brachial plexus or subclavian
artery and or vein in the region near the thoracic outlet.
 Commonly accepted medical diagnosis include:
i. Neurogenic TOS
ii. Vascular TOS: Arterial or venous
iii. Nonspecific TOS

4. Sites of entrapment
• Interscalene triangle
• Costoclavicular
space
• Axillary interval

5. Epidemiology/Etiology
 TOS affects approximately 8% of the population and is 3-4 times as frequent In
woman as in men between the age of 20 and 50 years.
 Congenital factors:
• Cervical rib
• Prolonged transverse process
• Anomalous muscles
• Fibrous anomalies (transversocostal, costocostal)
• Abnormalities of the insertion of the scalene muscles
• Fibrous muscular bands
• Exostosis of the first rib
• Cervicodorsal scoliosis
• Congenital uni- or bilateral elevated scapula
• Location of the A. or V. Subclavian in relation to the M. scalene anterior

6.  Acquired conditions:
• Postural factors
• Dropped shoulder condition
• Wrong work posture (standing or sitting without paying attention to the physiological curvature
of the spine)
• Heavy mammaries
• Trauma
• Clavicle fracture
• Rib fracture
• Hyperextension neck injury, whiplash
• Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long hours)

Muscular causes:
• Hypertrophy of the scalene muscles
• Decrease of the tonus of the M. trapezius, M. levator scapulae, M.rhomboids
• Shortening of the scalene muscles, M. trapezius, M. levator scapulae, pectoral muscles

7. Clinical Presentation
Arterial TOS Venous TOS Neurogenic TOS Nonspecific TOS
•Young adult
with vigorous
arm activity
•Pain in the hand
•Claudication
•Pallor
•Cold intolerance
•Paresthesias
•S/s usually appear
spontaneously
•Younger men with
vigorous arm activity
•Cyanosis
•Feeling of heaviness
•Paresthesia in fingers
and hand (result of
edema)
•Edema of the arm
•Hx of neck trauma
•Pain, paresthesia,
numbness, and/or
weakness
•Occipital headaches
•S/s present day and/or
night
•Loss of fine motor skills
•Cold intolerance
(possible Raynaud's
phenomenon)
•Objective weakness
•Compressors*: s/s
day>night
•Hx of neck trauma
•Pain, paresthesia, and
"feeling" of weakness
•Occipital headaches
•Nocturnal paresthesias
that often wake patient
•Loss of fine motor skills
•Cold intolerance
(possible Raynaud's
phenomenon)
•Subjective weakness
•Releasers*: s/s
night>day

8. Examination
 History
 Physical Examination[15][16]
 Observation
 - Posture
- Cyanosis
- Edema
- Paleness
- Atrophy
 Palpation
 - Temperature changes
- Supraclavicular fossa
- Scalene muscles (tenderness)
- Trapezius muscle (tenderness)

9.  Neurological Screen
 MMT & Flexibility of following muscles:
- Scalene
- Pectoralis major/minor
- Levator scapulae
- Sternocleidomastoid
- Serratus anterior

10. Special Tests
 Elevated Arm Stress/ Roos test
 Adson’s
 Wright’s
 Cyriax Release
 Supraclavicular Pressure
 Costoclavicular Maneuver
 Upper Limb Tension
 Cervical Rotation Lateral Flexion

11. Diagnostic Procedures
 Electrodiagnostic evaluation and imaging
 Nerve conduction studies ( Nerve conduction studies usually reveal decreased
ulnar sensorial potentials, decreased median action potentials, normal or close to
normal ulnar motor and median sensorial potentials)
 Electromyography
 venography and arteriography
 Cervical spine and chest x-rays
 MRI

12. Medical Management
 Nonsteroidal anti-inflammatory drugs
 Botulinum injections to the anterior and middle scalenes have also found to
temporarily reduce pain and spasm from neurovascular compression

13. Physiotherapy Management
 patient education
 Correct impaired posture
 Mobilize restricted neurological tissue
 Mobilize restricted joints, connective tissue, and muscle
 Improve muscle performance
 Correct faulty breathing pattern
 Progress functional independence

14. Surgical management
 Scalenectomy
 Removal of first rib
 Removal of cervical rib
 breast-reduction surgery