Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Thoracic Outlet Syndrome
Document related concepts
Transcript
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.
