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| | == Clinical Presentation == |
| '''Original Editors ''' - [[User:Xiomara Hernandez|Xiomara Hernandez]]
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| '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
| | <u>Release-phenomenon</u> |
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| == Search Strategy ==
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| Articles were searched on pubmed and www.pedro.org.au.<br>
| | The symptoms occur with work activities above the horizontal plan. The symptoms only occur after the decrease or removal of the compression. The longer the compression, the longer the latency time.<br>Example: worsening of the symptoms when elevating the arm to do such things as blow dry one's hair or put something on a high shelf (when the arm is depressed again and the compression of the vessels is removed, the symptoms occur).<br> |
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| == Definition/Description ==
| | <u>Physical presentation</u> |
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| Thoracic outlet syndrome (TOS) is a syndrome with a subdivision into a neurogenic and a vasculogenic subtypes.<br>The term is used to describe complaints resulting from compression of the brachial plexus, subclavian artery or subclavian vein due to the narrowing of the spaces in the thoracic outlet.
| | • In '''abduction''', patients with dropped shoulder TOS frequently demonstrate late and insufficient upward rotation of the scapula compared to the other side and/or to normal. This can often lead to a restriction of abduction range.<br>=> the deficit is due to inadequate shoulder girdle muscle control and reduced upward rotation of the scapula. <br>• In '''flexion''', the same tendency for depression and downward rotation is seen but is often overshadowed by an obvious winging of the scapula due to serratus anterior insufficiency.<br><br> |
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| == Clinically Relevant Anatomy == | | == Management / Interventions == |
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| <u>The description of the spaces in the thoracic outlet:</u><ref name="one">Thoracic outlet syndrome: anatomy. Erdogan Atasoy, MD. Hand Clin 20 (2004) 7–14 (level of evidence B)</ref><ref name="two">Surgery of peripheral nerves: a case-based approach. Rajiv Midha, Eric L. Zager. 2008 - 288 pages. (level of evidence C)</ref><ref name="three">http://emedicine.medscape.com/article/760477-overview</ref><ref name="four">http://web.me.com/paulrod/drtraceyreeb.com/Blog/Entries/2010/6/3_Thoracic_Outlet_Syndrome.html</ref> | | <u>Scapula settings and control</u><br> |
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| The '''interscalene''' triangle: This is the most proximal passageway of the thoracic outlet. This triangle is bordered by the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the medial surface of the first rib inferiorly. The brachial plexus and the subclavian artery pass through this space.
| | In the treatment you first have to start with scapula settings and control.<br>This is important to establishing normal scapula muscle recruitment and control in the resting position. Once this is achieved then the program is progressed to maintaining scapula control while both motion and load are applied. The programme begins in lower ranges of abduction and is gradually progressed further up into abduction and flexion range until muscles are being retrained in functional movement patterns at higher ranges of elevation. |
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| <br>The '''costoclavicular''' triangle: This second passageway is bordered anteriorly by the middle third of the clavicle, posteromedially by the first rib, and posterolaterally by the upper border of the scapula. The subclavian vein crosses anterior to the anterior scalene muscle. Just distal to the insterscalene triangle. The neurovascular bundle enters the costoclavicular triangle and then further enters the subcoracoïd space. | | <u>Control the humeral head position</u><br> |
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| <br>The '''subcoracoid''' or '''sub-pectoralis minor space''': This last passageway is beneath the coracoid process just under the pectoralis minor tendon.
| | It is also important to control the humeral head position. Specific drills are given to facilitate humeral head control. The most common aberrant position of the humeral head is an increase in anterior placement of the humeral head. A useful strategy to help facilitate co-contraction of the rotator cuff to help stabilize and centralize the humeral head is to facilitate a mid level isometric contraction of the rotator cuff by applying resistance to the humeral head (Dark et al., 2007).<br>Further on in the treatment this may be integrated into movement patterns. First in slow controlled concentric/eccentric motion drills, later isolated muscle strengthening drills. |
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| <br> | | <u>Serratus anterior recruitment and control </u> |
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| == Epidemiology /Etiology ==
| | Abduction external rotation strategies described above are often sufficient to trigger serratus anterior recruitment and control without the risk of over-activating pectoral minor muscle.<br><br> |
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| <u>''Congenital factors:''</u><br>• cervical rib<ref name="one" /><ref name="six" /><ref name="seven">Transaxillary First Rib Resection for Thoracic Outlet Syndrome. Harold C. Urschel, Jr., MD. Operative techniques in thoracic and cardiovascular surgery. 2005 (level of evidence B)</ref><br>• fibrous muscular bands<ref name="one" /><br>• abnormalities of the insertion of the scalene muscles<ref name="one" /><br>• exostosis of the first rib<br>• cervicodorsal scoliosis<ref name="five" /><br>• congenital uni- or bilateral elevated scapula<br>• location of the A. or V. Subclavian in relation to the M. scalene anterior
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| <u>''acquired conditions:''<br></u>• postural factors: <br>* dropped shoulder condition<ref name="one" /><ref name="nine" /><br>* wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine)<br>* heavy mammaries
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| • trauma:<ref name="five">Impact of massage therapy in the treatment of linked pathologies: Scoliosis, costovertebral dysfunction, and thoracic outlet syndrome. Michael Hamm, LMP. Journal of Bodywork and Movement Therapies (2006) 10, 12–20. (level of evidence C)</ref><br>* clavicle fracture<ref name="one" /><br>* rib fracture<ref name="one" /><br>* hyperextension neck injury, whiplash<ref name="three" /><ref name="six">Diagnosis of thoracic outlet syndrome. Richard J. Sanders MD, Sharon L. Hammond MD and Neal M. Rao BA. J Vasc Surg. 2007 Sep;46(3):601-4.(level of evidence B)</ref><br>* Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long hours)<ref name="three" />
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| • muscular causes:<br>* hypertrophy of the scalene muscles<br>* decrease of the tonus of the M. trapezius, M. levator scapulae, M.rhomboids<br>* shortening of the scalene muscles, M. trapezius, M. levator scapulae, pectoral muscles<u><br></u>
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| == Characteristics/Clinical Presentation ==
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| The clinical presentation depends on which anatomic structure is compressed in the area of the thoracic outlet.
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| [[Additional Information - Thoracic Outlet Syndrome|Release-phenomenon]] (= the release of the symptoms) can be present in tos.<br>
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| <u>The neurogenic presentation:</u><ref name="three" /><br>(mostly an ulnar nerve distribution)<br>• pain: In the area of the shoulder, neck, radiating to the arm, hand, chest and back of the head<ref name="five" /><ref name="seven" /><ref name="six" /><ref name="eight">Conservative treatment of thoracic outlet syndrome (TOS): Creating an evidence-based strategy through critical research appraisal.Konstantine C. Balakatounis, Antonios G. Angoules, Kalomoira A. Panagiotopoulou. Current Orthopaedics (2007) 21, 471–476 (level of evidence B)</ref><br>• paresthesias<ref name="six" /><ref name="eight" /><br>• hand weakness or motor loss<ref name="five" /><ref name="seven" /><ref name="six" /><br>• stiffness of the fingers<br>• tingling in the hand<ref name="five" /><br>• numbness<ref name="five" /><br>
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| <u>The arterial presentation:</u><ref name="three" /><br>(compression of the subclavian artery)<br>• coldness, weakness, heaviness and paleness of the hand<ref name="six" /><br>• increased transpiration of the hand<br>• pain<ref name="six" /><br>• ischemia<ref name="six" /><br>
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| <u>The Venous presentation:</u><ref name="three" /><br>(compression of the subclavian vein) <br>• edema/swelling of the hand and forearm<ref name="five" /><ref name="seven" /><ref name="six" /><br>• tensed feeling of the arm<br>• cyanosis<ref name="six" />
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| <u>Physical presentation:<ref name="nine" /></u> <br>• the scapula can be depressed at rest on the symptomatic side compared to the other side<ref name="nine">Thoracic outlet syndrome Part 2: Conservative management of thoracic outlet L.A.Watson, T.Pizzari S, Balster. Manual Therapy 15 (2010) 305-314 (level of evidence F)</ref><br>• [[Upper limb tension test A|ULTT ]]<ref name="six" /><br>• The scapula also demonstrates dysfunction through elevation motions such as [[Additional Information - Thoracic Outlet Syndrome|abduction ]](usually most provocative motion) and [[Additional Information - Thoracic Outlet Syndrome|flexion]].<br>• Increased anterior tilt of the scapula, frequently coupled with increased downward rotation of the scapula<br>• Decreased strength in many shoulder girdle muscles<ref name="seven" /><br>• An increased consistency of recruitment by other muscle groups such as M. rhomboids, M. levator scapulae and M. pectoral minor, leading to the scapula asymmetries commonly observed: downward rotation, depression and anterior tilt of the scapula.
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| == Differential Diagnosis <ref name="ten">http://www.ecentral.com/members/rsanders/</ref> ==
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| A paper on clinical manifestations, differentiation and treatment pathways of carpal tunnel syndrome included the following differential diagnostic options:<ref>Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome Part 1: Clinical manifestations, differentiation and treatment pathways . Man Ther. 2009 Dec;14(6):586-95. Epub 2009 Sep 9. (Grade of evidence F)</ref><br>
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| *[[Carpel Tunnel Syndrome|Carpal tunnel syndrome]]
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| *[[De Quervains|deQuervain’s tenosynovitis]]
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| *[[Lateral Epicondylitis|Lateral epicondylitis]]
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| *[[Medial Epicondylitis|Medial epicondylitis]]
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| *[[Complex Regional Pain Syndrome|Complex regional pain syndrome]] (CRPS I or II).
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| *Horner’s Syndrome
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| *Raynaud’s disease
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| *Cervical disease (especially discogenic)
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| *Brachial plexus trauma
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| *Systemic disorders: inflammatory disease, esophageal or cardiac disease
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| *Upper extremity deep venous thrombosis (UEDVT), Paget-Schroetter syndrome
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| *Rotator cuff pathology
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| *Glenohumeral joint instability
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| *Thoracic outlet syndrome
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| For the specific criteria, please refer to the mentioned paper.<br>
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| There are conditions that can coexist with TOS. It is important to identify these conditions because they should be treated separately. <br>These associated conditions include:<br>* [http://www.physio-pedia.com/index.php5?title=Carpel_Tunnel_Syndrome carpal tunnel syndrome]<br>* peripheral neuropathies (like ulnar nerve entrapment at the elbow, shoulder tendinitis and[http://www.physio-pedia.com/index.php5?title=Subacromial_Impingement impingement syndrome]) <br>* [http://www.physio-pedia.com/index.php5?title=Fibromyalgia fibromyalgia ]of the shoulder and neck muscles<br>* cervical disc disease (like [http://www.physio-pedia.com/index.php5?title=Cervical_Spondylosis cervical sponylosis] and herniated cervical disk)<br><br>
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| == Diagnostic Procedures ==
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| == Outcome Measures ==
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| == Examination ==
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| The following signs are used for the identification of TOS:<ref>Lee J, Laker S, Fredericson M. Thoracic outlet syndrome. PM R. 2010 Jan;2(1):64-70. (Grade of evidence E)</ref><br>* Tenderness over the scalene or supraclavicular region <br>* Reproducing symptoms by pressure or the Tinel maneuver in the supraclavicular or brachial plexus region <br>* Upper limb tension testing (ULTT) (e.g., neck side bending to the ipsilateral side causes concordant symptoms) <br>* Objective neurologic deficits <br>* Dynamic positioning provocation tests <br>
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| <blockquote>- [[Roos Stress Test|Roos test]]</blockquote><blockquote>- Wright test </blockquote><blockquote>- [[Adsons Test|Adson maneuver]]</blockquote><blockquote>- [[Halstead Test|Halstead (costoclavicular) maneuver ]] </blockquote>
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| The dynamic provocation tests referred here were originally designed to ascertain the presence of vascular compromise but have more recently been used or adapted to confirm the diagosis of TOS.<br>Because of this original purpose, these tests show a high rate of false positives and the reproducibility of the correct symptoms forms a better indication than a diminished pulse in identifying TOS. <br>
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| == Medical Management <br> ==
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| Treatment may be either operative or non-operative. Current consensus suggests that surgery should follow after conservative treatment failure or/and vascular complications; therefore, it is underlined that conservative treatment is the first option in the treatment of TOS. <ref name="eight" /><br>
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| Surgery for TOS consists of decompression of the anterior shoulder region usually with resection of the first rib.<ref name="seven" /><ref name="eight" />
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| == Physical Therapy Management <br> ==
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| <br><u>The conservative treatment include:</u><br>• Cervical, thoracic and first rib mobilization techniques<br>• Posture correction<ref name="seven" /><br>• Massage<ref name="five" /><ref name="seven" /><br>• Heat application<ref name="eight" /><br>• home exercises <ref name="eight" /><br>• Stretching and PNF (of pectoral muscle and M. scalene) <ref name="five" /><ref name="seven" /><ref name="eight" /><br>• strengthening of appropriate muscles <ref name="seven" /><ref name="eight" />,<ref name="nine" /><br>• physical modalities<ref name="seven" /><ref name="eight" /><br>• respiratory exercise<ref name="eight" /><br>• taping<ref name="nine" /><br>• modify or improve the workplace ergonomics (=>typical postural deterioration)<ref name="eight" /><br>• neuromeningeal treatment techniques<br>• advicing in connection with sleeping positions<br>• shoulder shrugs<br>• progressive resisted shoulder elevation exercise<ref name="eight" /><br>• [[Additional Information - Thoracic Outlet Syndrome|scapula settings and control ]]<ref name="nine" /><br>• [[Additional Information - Thoracic Outlet Syndrome|learn to control the humeral head position]]<ref name="nine" /><br>• [[Additional Information - Thoracic Outlet Syndrome|serratus anterior recruitement and control]]<ref name="nine" />
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| == Key Research ==
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| add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
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| == Resources <br> ==
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| == Clinical Bottom Line ==
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
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| see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
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| == References ==
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| see [[Adding References|adding references tutorial]].
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| <references />
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| [[Category:Vrije_Universiteit_Brussel_Project]]
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