Management of Thoracic Outlet Syndrome
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Search Strategy[edit | edit source]
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Definition/Description[edit | edit source]
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Epidemiology/Etiology[edit | edit source]
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Characteristics/Clinical Presentation[edit | edit source]
Signs and symptoms of thoracic outlet syndrome are variable from patient to patient due to the location of nerve and/or vascular involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Patients with thoracic outlet syndrome will most likely present with paresthesia in upper extremity, neck pain, trapezius pain, supraclavicular pain, chest pain, and occipital pain. Patients with upper plexus (C5,6,7) involvement can present with pain in anterior neck from the clavicle up to and including the mandible, ear, and mastoid region. These symptoms can continue into the anterior chest, scapular region, trapezius and into lateral part of the arm continuing all the way to the thumb and index finger. Patients with lower plexus (C8,T1) involvement typically present with symptoms along the medial side of the arm and hand with potential involvement in the anterior shoulder and axillary region. There are four categories of thoracic outlet syndrome and each presents with unique signs and symptoms (see Table 1). Typically thoracic outlet syndrome does not follow a dermatomal or myotomal pattern unless there is nerve root involvement which will be important in determining your PT diagnosis and planning your treatment.
Arterial TOS | Venous TOS | True TOS | Disputed Neurogenic TOS |
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Compressors* - a patient that experiences symptoms throughout the daytime while using prolonged postures resulting in increased tension or compression of the thoracic outlet
Releasers* - a patient that experiences a release phenomenon (release of tension or compression to thoracic outlet) that often awakes them at night
Differential Diagnosis[edit | edit source]
Due the variability of presentation TOS can be difficult to tease out from other pathologies with common presentations. A thorough history and evaluation must be done to determine if the patient’s symptoms are truly TOS. The following pathologies are common differential diagnosis for TOS:
• Carpal tunnel syndrome
• DeQuervain’s tenosynovitis
• Lateral/medial epicondylitis
• Complex regional pain syndrome
• Horner’s Syndrome
• Raynaud’s disease
• Nerve root involvement
Systematic causes of brachial plexus pain include:
• Pancoast’s Syndrome
• Radiation induced brachial plexopathy
• Parsonage Turner Syndrome
Outcome Measures[edit | edit source]
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Examination
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The following includes common examination findings seen with TOS that should be evaluated; however, this is not an all-inclusive list and examination should be individualized to the patient.
History
- Make sure to take a thorough history, clear any red flags, and ask the patient how signs/symptoms have affected his/her function.
- Type of symptoms
- Location and amplitude of symptoms
- Irritability of symptoms
- Onset and development over time
- Aggravating/alleviating factors
- Disability
Physical Examination
- Observation
- Posture
- Cyanosis
- Edema
- Paleness
- Atrophy
- Palpation
- Temperature changes
- Supraclavicular fossa
- Neurological Screen
- MMT & Flexibility
- Scalene
- Pectoralis major/minor
- Levator scapuae
- Sternocleidomastoid
- Serratus anterior
Special Tests
- Elevated Arm Stress
- Adson's
- Wright's
- Cyriax Release
- Supraclavicular Pressure
- Costoclavicular Maneuver
- Upper Limb Tension
- Cervical Rotation Lateral Flexion
Test | Sensitivity | Specificity | LR+ | LR- |
Elevated Arm Stress | 52-84% | 30-100% | 1.2-5.2 | 0.4-0.53 |
Adson's | 79% | 74-100% | 3.29 | 0.28 |
Wright's | 70-90% | 29-53% | 1.27-1.49 | 0.34-0.57 |
Cyriax Release | NT | 77-97% | NA | NA |
Supraclavicular Pressure | NT | 85-98% | NA | NA |
Costoclavicular Maneuver | NT | 53-100% | NA | NA |
Upper Limb Tension | 90% | 38% | 1.5 | 0.3 |
Cervical Rotation Lateral Flexion | 100% | NT | NA | NA |
Medical Management
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Surgical management of TOS should only be considered after conservative treatment has been proven ineffective. However, limb-threatening complications of vascular TOS have been indicated for surgical intervention.
Physical Therapy Management
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Key Research[edit | edit source]
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Resources
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Clinical Bottom Line[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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