Management of Thoracic Outlet Syndrome
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Original Editors - Xiomara Hernandez
Top Contributors - Alicia Fernandes
Search Strategy[edit | edit source]
Articles were searched on pubmed and www.pedro.org.au.
Definition/Description[edit | edit source]
Thoracic outlet syndrome (TOS) is a syndrome with a subdivision into a neurogenic and a vasculogenic subtypes.
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.
Clinically Relevant Anatomy[edit | edit source]
The description of the spaces in the thoracic outlet:[1][2][3][4]
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.
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.
The subcoracoid or sub-pectoralis minor space: This last passageway is beneath the coracoid process just under the pectoralis minor tendon.
Epidemiology /Etiology[edit | edit source]
Congenital factors:
• cervical rib[1][5][6]
• fibrous muscular bands[1]
• abnormalities of the insertion of the scalene muscles[1]
• exostosis of the first rib
• cervicodorsal scoliosis[7]
• congenital uni- or bilateral elevated scapula
• location of the A. or V. Subclavian in relation to the M. scalene anterior
acquired conditions:
• postural factors:
* dropped shoulder condition[1][8]
* wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine)
* heavy mammaries
• trauma:[7]
* clavicle fracture[1]
* rib fracture[1]
* hyperextension neck injury, whiplash[3][5]
* Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long hours)[3]
• 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
Characteristics/Clinical Presentation[edit | edit source]
The clinical presentation depends on which anatomic structure is compressed in the area of the thoracic outlet.
Release-phenomenon (= the release of the symptoms) can be present in tos.
The neurogenic presentation:[3]
(mostly an ulnar nerve distribution)
• pain: In the area of the shoulder, neck, radiating to the arm, hand, chest and back of the head[7][6][5][9]
• paresthesias[5][9]
• hand weakness or motor loss[7][6][5]
• stiffness of the fingers
• tingling in the hand[7]
• numbness[7]
The arterial presentation:[3]
(compression of the subclavian artery)
• coldness, weakness, heaviness and paleness of the hand[5]
• increased transpiration of the hand
• pain[5]
• ischemia[5]
The Venous presentation:[3]
(compression of the subclavian vein)
• edema/swelling of the hand and forearm[7][6][5]
• tensed feeling of the arm
• cyanosis[5]
Physical presentation:[8]
• the scapula can be depressed at rest on the symptomatic side compared to the other side[8]
• ULTT [5]
• The scapula also demonstrates dysfunction through elevation motions such as abduction (usually most provocative motion) and flexion.
• Increased anterior tilt of the scapula, frequently coupled with increased downward rotation of the scapula
• Decreased strength in many shoulder girdle muscles[6]
• 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.
Differential Diagnosis [10][edit | edit source]
A paper on clinical manifestations, differentiation and treatment pathways of carpal tunnel syndrome included the following differential diagnostic options:[11]
- Carpal tunnel syndrome
- deQuervain’s tenosynovitis
- Lateral epicondylitis
- Medial epicondylitis
- Complex regional pain syndrome (CRPS I or II).
- Horner’s Syndrome
- Raynaud’s disease
- Cervical disease (especially discogenic)
- Brachial plexus trauma
- Systemic disorders: inflammatory disease, esophageal or cardiac disease
- Upper extremity deep venous thrombosis (UEDVT), Paget-Schroetter syndrome
- Rotator cuff pathology
- Glenohumeral joint instability
- Thoracic outlet syndrome
For the specific criteria, please refer to the mentioned paper.
There are conditions that can coexist with TOS. It is important to identify these conditions because they should be treated separately.
These associated conditions include:
* carpal tunnel syndrome
* peripheral neuropathies (like ulnar nerve entrapment at the elbow, shoulder tendinitis andimpingement syndrome)
* fibromyalgia of the shoulder and neck muscles
* cervical disc disease (like cervical sponylosis and herniated cervical disk)
Diagnostic Procedures[edit | edit source]
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Outcome Measures[edit | edit source]
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Examination[edit | edit source]
The following signs are used for the identification of TOS:[12]
* Tenderness over the scalene or supraclavicular region
* Reproducing symptoms by pressure or the Tinel maneuver in the supraclavicular or brachial plexus region
* Upper limb tension testing (ULTT) (e.g., neck side bending to the ipsilateral side causes concordant symptoms)
* Objective neurologic deficits
* Dynamic positioning provocation tests
- Wright test
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.
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.
Medical Management
[edit | edit source]
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. [9]
Surgery for TOS consists of decompression of the anterior shoulder region usually with resection of the first rib.[6][9]
Physical Therapy Management
[edit | edit source]
The conservative treatment include:
• Cervical, thoracic and first rib mobilization techniques
• Posture correction[6]
• Massage[7][6]
• Heat application[9]
• home exercises [9]
• Stretching and PNF (of pectoral muscle and M. scalene) [7][6][9]
• strengthening of appropriate muscles [6][9],[8]
• physical modalities[6][9]
• respiratory exercise[9]
• taping[8]
• modify or improve the workplace ergonomics (=>typical postural deterioration)[9]
• neuromeningeal treatment techniques
• advicing in connection with sleeping positions
• shoulder shrugs
• progressive resisted shoulder elevation exercise[9]
• scapula settings and control [8]
• learn to control the humeral head position[8]
• serratus anterior recruitement and control[8]
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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- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Thoracic outlet syndrome: anatomy. Erdogan Atasoy, MD. Hand Clin 20 (2004) 7–14 (level of evidence B)
- ↑ Surgery of peripheral nerves: a case-based approach. Rajiv Midha, Eric L. Zager. 2008 - 288 pages. (level of evidence C)
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 http://emedicine.medscape.com/article/760477-overview
- ↑ http://web.me.com/paulrod/drtraceyreeb.com/Blog/Entries/2010/6/3_Thoracic_Outlet_Syndrome.html
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 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)
- ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 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)
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 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)
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 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)
- ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 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)
- ↑ http://www.ecentral.com/members/rsanders/
- ↑ 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)
- ↑ Lee J, Laker S, Fredericson M. Thoracic outlet syndrome. PM R. 2010 Jan;2(1):64-70. (Grade of evidence E)
