Management of Thoracic Outlet Syndrome

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Search Strategy

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Definition/Description

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Epidemiology/Etiology

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Characteristics/Clinical Presentation

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
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

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

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

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Examination

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Medical Management

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

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Clinical Bottom Line

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