Download Thoracic Outlet Syndrome

THORACIC OUTLET
SYNDROME
John Broussard, DO
Sports Medicine Fellow
Institute for Non-Surgical Orthopedics
Larkin Community Hospital
Definition
• A group of syndromes in which biomechanical
obstructions are believed to compress or obstruct
structures in the thoracic outlet
• Subclavian artery & vein
• Axillary artery
• Cords of brachial plexus
TOS Symptoms
• Arterial
• Numbness of arms/hands
• Tingling of arms/hands
• Positional weakness
• Discoloration (pale/white hands)
• Venous
• Swelling of fingers and hands
• Heaviness of UEs
• Discoloration (blue)
• Nerves
• UE pain
• Paresthesias of ulnar distribution
• Weakness of hands
• Clumsiness of hands
• Coldness of hands
• Tiredness, heaviness and
paresthesias on elevation of UEs
• Shoulder and Neck
• Pain
• Tightness
• Chest Wall
• Anginal chest pain (heavy or
squeezing in midsternal area of
chest)
• Inter/para-scapular pain (along
medial shoulder blade)
• Head
• Headaches
• “funny feelings” in face and ear
• Vertebral Artery
• Dizziness
• Lightheadedness
Anatomy
• Thoracic outlet?
• Borders
• Anteriorly: manubrium
• Posteriorly: Body of T1
• Laterally: 1st and 2nd ribs (and their costal cartilage)
• Articulations
• Acromioclavicular
• Sternoclavicular
Anatomy
• “Sibson’s Fascia” = cervico-thoracic fascia
• Runs from root of neck  lower boundary of axilla
• (TP C7-border of rib 1)
• Tightly confines the neurovascular supply to the arm
• Great lymph channels (ascending and descending terminal ducts)
pass through Sibson’s fascia.
Anatomy
• Neurovascular bundle
• Subclavian a. (b/w 1st rib and scalenes)
• Subclavian v. (anterior to anterior scalene)
• Brachial plexus (C5-T1) (more post. and lateral to subclavian a.)
Innervation
• Sympathetic
• Brachial plexus (C7-T1): shoulder girdle and upper extremity
• T1-T4: head, neck & brain
• T1-T8: upper extremity
• T1-T6: heart & lungs
• Parasympathetic
• Vagus: heart, lungs, upper GI, kidneys
Etiology
• All TOSs occur due to a disruption or alteration of the
normal anatomy of the thoracic outlet.
• Symptoms of TOS are DIRECTLY related to the structures
disrupted:
• Shoulder or arm pain
• Weakness
• Paresthesias
• Claudication
• Raynaud’s phenomenon
• Ischemic tissue loss
• Gangrene
Predisposing Factors to TOS
• Intrinsic:
• Anterior scalene tightness
• Nerve root irritation, spondylosis, facet joint inflammation  muscle spasm
• Pectoralis minor tightness
• Repetitive overhead activity (shoulder elevation & hyperabduction)
• Costoclavicular approximation (b/w clavicle, 1st rib, support structures)
• Postural deficiencies or carrying heavy objects
• Cervical ribs
• Slender body habitus
• Extrinsic
• Trauma (contusion, hematoma, clavicular fx, whiplash)
• Unusual sleeping positions
• Occupations w/ unusual arm postures
• Painters, mechanics, military recruits, backpackers, students
• Athletes
• Swimmers, baseball pitchers, volleyball players, tennis players
Compression of neurovascular bundle
• 3 locations:
• b/w anterior and middle scalenes
• b/w clavicle and 1st rib
• b/w pectoralis minor and upper ribs
DDx of TOS
• Cervical nerve root compression (radiculopathy)
• Pancoast Tumor (lung apex reaches 2/3 cm into neck)
• Simple SD of ribs, clavicles, cervicals, thoracic spine
• Neurofibromas
• Cervical spondylosis
• Cervical disc herniation
• Carpal tunnel syndrome
• **Any/all may coexist w/ TOS**
Provocative Tests for TOS
• Adson’s Test (b/w scalenes)
• Costoclavicular (Military posture) test (b/w clavicle & 1st rib)
• Hyperabduction test (under pectoralis minor)
• Roos Test (Elevated Arm Stress Test)
• ER shoulders, elbows behind head. Open/close hands slowly x3 min.
• Pos: pain, heaviness or profound arm weakness or tingling/numbness
• Spurling Test (not specific for TOS)
Adson’s Test
Costoclavicular Test
Roos Test
Treatment Overview
• Protocol
• Identify type and cause of compression
• Optimize normal function and treat all somatic dysfunction
• Suggestions
• Exercise—stretching program
• Correct biomechanics—assess daily life movements of patient
• “Why now?”
• Meds: muscle relaxants, NSAIDs, Botox
• Biofeedback
• OMT
• Massage
• Physical Therapy
• Yoga
Treatment: OMT
• Myofascial release of thoracic outlet
• Normalize vertebral SD (C2-C7 and upper thoracics)
• Upper ribs (1st rib superior subluxation w/ shortening of
scalene muscles)
• Appendages (SC, AC, GH)
• Lymphatic treatment  increase lymph flow
• TPIs
• Spray and stretch
• Acupuncture
OMT
• Upper Thoracic HVLA
• Chin pivot thrust
• Dysfunction: T1 FRLSL
• Patient in prone position w/ chin on table
• Stand at head of patient, opposite to posterior
•
•
•
•
•
TP.
Place left hypothenar eminence on left TP of T1.
With right hand, SB pt’s head to the right to max
tissue tension while maintaining chin on table.
Rotate head away to obtain max tissue tension.
During exhalation, apply HVLA thrust w/ left hand
directed anteriorly, laterally, and inferiorly while
stabilizing the head w/ right hand.
Recheck.
OMT
• SD: 1st Rib inhalation
• Still Technique
Patient supine.
Standing at side of patient on side of dysfuntion.
Flex pt’s elbow and place their palm on chest.
Place pads of index finger on pt’s 1st rib.
Using opposite hand, grasp the elbow and apply
longitudinal compression through humerus.
• Using the elbow as a lever, pt’s arm is circumducted
clockwise by moving UE medially until elbow lines
up w/ head of pt’s 1st rib.
• The arc of motion from this position is lateral and
inferior, continuing circumduction motion, and
compression, w/ patient’s arm ending at the
midaxillary line.
• Recheck.
•
•
•
•
•
OMT
• Anterior & Middle Scalenes
• O: TP C2-C7
• I: 1st Rib
• A: Flexion and sidebending of C-spine
• Counterstrain
• Find the tender point, wrap around it.
• Hint: Follow the action of the muscle.
• Hold until tissues relax, passively return to resting.
• Recheck.
• May add traction and passively return to rest (Still)
if no improvement.
OMT
• Pectoralis minor muscle
• O: Anterior surface ribs 3-5
• I: Via tendon to medial aspect of coracoid
process of scapula. (Part or all of tendon may
transverse this process and continue into
coracoacromial ligament)
• A: Scapula protraction, rotation of scapula
downwards
• Counterstrain
• Find the tender point, wrap around it.
• Hold until tissues relax, passively return to
rest.
• Recheck.
OMT
• Cervicles
• Whichever you are comfortable with or patient (or tissues) will allow:
• Counterstrain
• Still’s
• HVLA
• Caution against muscle energy
Treatment
• Self-Stretching
• Scalenes and pectoral muscles
• Hold 30 sec., 10 reps bid
• WILL exacerbate symptoms
• Pain (deep ache) should not persist after stretch released
• Strengthening exercises for trapezius and levator scapulae
• Massage
• Cross-friction (pec minor and scalenes)
• Shoulder girdle
References
• DiGiovanna E, Schiowitz S. An osteopathic approach to diagnosis and
treatment. Philadelphia; JB Lippincott Co, 1991:45-53.
• Kai Y, Oyama M, Kurose S, et al. Neurogenic thoracic outlet syndrome in
whiplash injury. J Spinal Disord 2001;4:487-493.
• Karageanes S. Principles of Manual Sports Medicine. LWW, 2005: 268-293.
• Kulund DN. The injured athlete, 2nd ed. Philadelphia: JB Lippincott Co 1988.