Thoracic Outlet Syndrome

[physiogopi]

I need a effective treatment technique for Thoracic Outlet Syndrome. The patient is a 18 year old female, with no major complications.

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[Ozben]

Strengthening upper trapezius (shoulder shrugging exercises) are the usual way to go. Must admit the few I have seen responded fairly quickly to this. This might be worth a post in the musculoskeletal section to get more replies.

[sdkashif]

Use modalities to treat pain. You may use any one of them. These are superficial heating methods like Infrared, electrical heating pads, moist heat packs, etc & deep heating methods which are SWD, Micro wave diathermy, ultrasound. TENS and Interferential are also helpful.

Strength and endurance training exercises for the shoulder elevators.

Stretching exercises especially for the scalene muscles and pectoralis minor.

Posture correction exercises

Moblization and manipulation procedures to address the joint stiffness in the spine. (Moblization of the first rib)

Stretch and spray therapy as described by Jenet Travell and D.G. Simon ( Myofascial pain and Dysfunction)

I think that this will be of help to you.

[Physiobase]

Firstly here's an overview of TOS gained from various websites. This should give you a starting point for a more specific assessment of the causative factors, before deciding on a treatment approach.

Thoracic outlet syndrome is actually a collection of syndromes brought about by abnormal compression/pressure on the nerves and vessels in the thoracic outlet area. This is usually caused by bony, ligamentous or muscular obstacles between the cervical spine and the lower border of the axilla. The specific structures compressed are usually the nerves of the branchial plexus and occasionally the subclavian artery or subclavian vein.

Vascular symptoms include:

• 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 include:

• Parasthesia 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

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, postural weakness or changes.

Depending on the exact site of injury and the injury component of the neurovascular bundle, three distinct syndromes or a combination thereof may be encountered. One, neurological syndrome - Two, arterial syndrome - Three, venous syndrome. Each will have varying signs and symptoms. For more information have a look at the Thoracic Outlet Syndrome Website.

Below is a list of the component syndromes which comprise thoracic outlet syndrome along with a brief description of each.

Anterior scalene tightness

Compression of the interscalene space between the anterior and middle scalene muscles-probably from nerve root irritation, spondylosis or facet joint inflammation leading to muscle spasm.

Cervical Rib Syndrome

A variation of the Scalenus Anticus Syndrome is the Cervical Rib Syndrome. In this syndrome, it is an osseous anomaly, not muscular hypertrophy, that is responsible for the compression. Cervical ribs are hereditary elongations of the transverse processes of the C7 vertebrae. They may be unilateral or bilateral.

Costoclavicular approximation

Compression in 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.

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).

[sdkashif]

Thanks physiobase for adding valuable reply.

[sdkashif]

Let me also add the link to this useful article about the edgelow procedure in treatment of thoracic outlet syndrome.


eeshop.unl.edu/text/findadoc.txt

[zisuer]

Use modalities to treat pain. You may use any one of them. These are superficial heating methods like Infrared, electrical heating pads, moist heat packs, etc & deep heating methods which are SWD, Micro wave diathermy, ultrasound. TENS and Interferential are also helpful.

Strength and endurance training exercises for the shoulder elevators.

Stretching exercises especially for the scalene muscles and pectoralis minor.

Posture correction exercises

Moblization and manipulation procedures to address the joint stiffness in the spine. (Moblization of the first rib)

Stretch and spray therapy as described by Jenet Travell and D.G. Simon ( Myofascial pain and Dysfunction)

I think that this will be of help to you.

I am wondering where you usually use the modalities for pain? They may have pain totally unrelated to the structure at fault.

[zisuer]

I have a same age female client. I have TOS in my mind. Therefore, I educate her about the posture and avoiding aggravating activities. SHe had tight scalenes and pec minor, I gave her the streching ex's. I also gave her the scapular retractors strengthening ex's. SHE also has winging of scapular, esp when she lowering her arm. So serratus ant activation ex's. After 1st visit, she reported her symtoms slightly worse. We may irritate her by doing assessment. I will see how she is doing when she visit me next time. I'll let you know.

She doesn't like the heat and TENS. Her upper trapezius is obvious hypertrophy ( she has the condition for 2 years). Anybody can give me some clue, why this happened? If the shoulder shrug still approprate? and if the patient get worse again or do not getting better, should I refer her to the physician to seek surgery help, because she had sensation change , thumb numbness and C6 myotome very mild weakness before she saw me.

[Tortolagal]

I am a TOS patient and would like to respond as such. Would also add that I'm conducting independent research on effective (non-surgical) treatments for TOS and collecting stories from TOS patitents about what treatments have been most effective for them.
As a person in constant pain from this condition, I tried everything. Chiropractic, nerve blocks, cortisone injections, standard physical therapy, massage etc. - almost all of which exacerbated my symptoms. The ONLY thing that helped me was Manual Therapy. Once my neck and Thoracic spine were moblized and "put back in order", only then did additional therapies begin helping me. Please consider Manual Therapy for any of your patients with TOS (w/out extra cervical rib involvement).
I'll be happy to put folks in touch with certified practitioners if interested.
I'm not claiming MT will work for everyone, but want folks to at least have access to it before going under the knife and spending all of their savings on medical bills like I did.

[BenMort]

I have also found manual therapy to be effective. A patient of mine is showing ulnar nerve signs and poor posture. The patient's symptoms are aggravated with mobilisation of the cervical spine but his symptoms improve week on week. Im not convinced it is TOS but similar treatment strategies still apply. I have also found static opening techniques, so holding his cervical spine in a position opening the ipsilateral side helps to relieve symptoms. I ahve not however tried mobilisation fo the first rib and wondered how effetcive people had found this?

[JayPhysio]

Before treatment:

First confirm the diagnosis with:

• Adson or Scalene Maneuver
• 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.
  
  Costoclavicular Maneuver
• The examiner locates the radial pulse and draws the patient's shoulder down and back as the patient lifts their chest in an exaggerated "at attention" posture. 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 back-pack or a heavy jacket.
  
  Allen Test
• The examiner flexes the patient's elbow to 90 degrees while the shoulder is 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.
  
  
• Neural tissue provocation tests for radial, ulnar and median nerves.
  
• Scalene, pec, upper traps length
• Scalene, pec, upper traps, lower traps bulk
  
• Cervical, Thoracic and upper rib mobility

There is NEVER a standard treatment you can give for TOS as there are so many factors that can be or may not be contributing.

physiogopi to ask for "effective treatment technique" does not take in to consideration your assessment, and hence you can not clinically reason your treatment.

Treatment is simple if you test appropriately:

• Tightness (or trigger points) - massage, stretch, acupuncture/dry needling
• Stiffness - mobilise/manipulate
• Poor posture - tape into good posture initially and then progress to postural exercises (retractors and elevators) and address workplace ergonomics
• Positive NTPT - nerve flossing/gliding techniques
• Small bulk - strengthen with free weights/theraband/good posture

@Tortolagal: I am surprised to hear that it took so long for you to find someone who does manual therapy. As far as I'm aware, Manual therapy is the mainstay of physiotherapists around the world in musculoskeletal practice.

@Benmort: Sounds to be more a radiculopathy. Have you assessed scalene length? Try a myofascial release through the scalenes, and a scalene stretch for home programme.

Jay Physio

[BenMort]

Great post JayPhysio, I have not seen a couple of those tests before.

The patient of mine has now been discharged, with a home prgram of tecthing and maintinnance exercises and I have not heard anything so I think it ended well! Therefore I can say that the radiculopathy as you termed it was effetcively treated with manual therapy, cervical poterior anterior and unilateral mobilisation as well as manual and stretching exercises.

[oyvind]

Hi,

I'd have to agree with others that a clinical reasoning process would be required for giving advice. "Effective treatment technique" depends on findings...I'll give you an example: in the case of an elevated shoulder girdle/hypertone upper traps - couldn't this just be a useful adaptive response to a hot neural mechanosensitivity? The same could go for a hypo first rib, hypertone scalenes etc, you name it. Unless you come up with a thorough report on reasoning process it's potentially harmful to follow our advice. If that's not interesting I would advice you to get in a position where you would have some experienced collegues to learn from.

Lyn Watson et al wrote two masterclasses on the subject, would advice you to have a dig into those.

Øyvind

[Liginamite]

How are you doing, Tortolagal? It's been a while. I have been recently diagnosed and am looking for treatment options. Surgery is not on the table for now; the doc actually recommended against it unless I was facing my own death. I am not nearly there yet.