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Thoracic Outlet Syndrome
Normal Anatomy
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The neurovascular container described as the ‘thoracic outlet’ runs proximally from the
cervicoaxillary canal, distally to the axilla
Within this container are three important neurovascular structures: the subclavian artery,
subclavian vein and the trunks of the brachial plexus
The thoracic outlet is the term used to describe a series of spaces extending from the
cervical spine and mediastinum to the lower border of the pectoralis minor muscle
These structures run through three compartments within the thoracic outlet:
o The interscalene triangle
 Boundaries are made up of the anterior scalene (anteriorly), the middle
scalene (posteriorly) and the first rib (inferiorly)
 Very small at rest but can be made even smaller with certain provocative
positions of the upper limbs and neck
o The costoclavicular space
 Made up of the clavicle (anteriorly), first rib (posteromedially) and the upper
border of the scapular (posterolaterally)
o The subcoracoid space
 Below the coracoid process and deep to the pectoralis minor tendon
 Also known as retropectoralis minor space or thoraco-coracopectoral space
Pathology
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Compression or compromise of the brachial plexus, subclavian artery or the subclavian vein
at any of the three spaces along their pathway (interscalene triangle, costoclavicular space
or subcoracoid space)
Resulting in pain, paraesthesia, weakness or discomfort in the upper limb
Symptoms do not follow a nerve root pattern
Mechanism of injury
Traumatic
 Very rare
 Traumatic thoracic outlet syndrome can occur secondary to clavicle fracture, posterior
subluxation of acromioclavicular joint or road traffic accidents
Insidious
 Congenital abnormalities such as first rib deformities, cervical rib development, deformity of
the C7 transverse process or an enlarged scalene tubercle
 Poor posture
 Occupational stressors i.e repetitive overuse
 Associated soft tissue adaptations e.g hypertonic pec minor or scalenes
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Co-Existing or Associated Pathologies
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Whiplash Associated Disorder
Chronic Obstructive Pulmonary Disease (shortening of scalenes -muscle of inhalation)
Presence of cervical rib
Deformity of first rib
Deformity of C7 transverse process
Fracture or trauma to clavicle, sternum or acromioclavicular joint
Classification
Thoracic outlet syndrome can be classified according to which structures are being compromised.
Thoracic Outlet Syndrome
1. Vascular Thoracic Outlet
Syndrome
Arterial TOS
a. Compression of the b.
subclavian artery
which is very rare but
presents as unilateral
pain, with ischemia
and necrosis following
as a result of occlusion
to the vessel.
2. Neurogenic Thoracic Outlet
Syndrome
Venous TOS
True Neurogenic TOS
Very rare, but is
almost always caused
by a bony anomaly
compressing the
brachial plexus,
patient will
experience unilateral
pain, weakness,
paraesthesia but not
in a nerve root
pattern.
Compression of the
subclavian vein, very
rare, patient often
experiences sudden
unilateral pain after
having arm elevated,
this causes
spontaneous
thrombosis of the vein
resulting in cyanosis
and swelling of the
entire limb.
Symptomatic TOS
Most common of the
4 varieties and is often
caused by acute
trauma (WAD) or
repetitive trauma,
NOT an anatomical
anomaly. Presents
with unilateral arm
pain, weakness,
paraesthesia but not
in a nerve root
pattern. (Also known
as disputed or nonspecific thoracic outlet
syndrome.)
Examination
Each classification of thoracic outlet syndrome will present differently, therefore careful subjective
assessment must be taken including history and mechanism of injury as well as an extensive objective
assessment, ruling out peripheral nerve compression or cervical radiculopathies.
Subjective
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More common in females than men (ratio between 2:1 and 4:1)
Normally aged between 20-50 years
Unilateral symptoms
Pain can be reported in the shoulder, neck, trapezius, chest, occipitals, forearm, hand and
fingers
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Paraesthesia - often in the forearm and hand
Weakness or fatigue of muscles in the affected limb
Change in skin colour, temperature, hair growth and oedema
Reduction of arterial pulses in the affected extremity
Aggravating factors are typically sustained shoulder elevation, suspensory holding activities
(i.e painting ceiling), lying on the arm, carrying a handbag or prolonged postures
Many report pain waking them at night
Objective
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Abnormal cervical, thoracic and shoulder posture
Restricted and painful cervical, thoracic and or upper limb ROM (shoulder through to
fingers)
Pain on sustained arm elevation
Poor scapular positioning at rest and moving
Change in skin temperature
Change in sensation (will present in non-dermatomal pattern)
Change in power (will present in non-myotomal pattern)
Hypermobility or hypermobility of cervical, thoracic or upper limb joints.
Tightness and pain on palpation of surrounding soft tissues
Special Tests
There are a number of classic provocation tests for thoracic outlet syndrome. However, these have
been reported to be unreliable and frequent false positives, with poor specificity, sensitivity and
predictability.
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Adson’s Test
Wright’s Test
Roos Test
The military brace
Postural and scapular corrective exercises
Tinnels at the supraclavicular fossa
Morley Test
Further investigation
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Chest X-Ray with or without angiography (vascular)
MRI
Ultrasound with Doppler
Nerve conduction studies
Anterior scalene block
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Management
Conservative
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Advice for posture, activity modification, avoiding aggravating factors and pain
Reduce pain, swelling and inflammation
o Medications (opioids, NSAIDs)
o Ice and or heat
o Light soft tissue massage
Increase Range of Movement
o Decrease tone
 Soft tissue massage: paraspinals, scalenes, trapezius, pectoralis minor,
pathway of peripheral nerves
 Diaphragmatic breathing (offloads scalenes)
 Stretching
 Light ROM exercises
 Dry needling
o Improve Joint Movement
 Joint mobs: cervical spine, thoracic spine, glenohumeral joint, first rib
 Soft tissue massage
 Manipulations
Restore Normal motor control and strength
o Deep neck flexors, scapular control and mobility, core stability, shoulder dynamic
stability (rotator cuff)
Restore dynamic stability and proprioception
o Strengthen under load, improve scapular mobility throughout range, sport and
activity specific
Surgery
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Pec minor release
Excision of first rib
Removal of cervical rib if present
Surgery for thromboectomy if indicated following venous vascular TOS
Botulinim Toxin injections at hypertonic muscles has been investigated
Scalenectomy and scalenotomy
Removal of callus from previous clavicle fracture
Subclavian artery decompression and or repair
References
(Abdul-Jabar, Rashid et al. 2009, Watson, Pizzari et al. 2009, Hooper, Denton et al. 2010, Hooper,
Denton et al. 2010, Watson, Pizzari et al. 2010, Twaij, Rolls et al. 2013, Povlsen, Hansson et al. 2014)
Abdul-Jabar, H., A. Rashid and F. Lam (2009). "Thoracic outlet syndrome." Orthopaedics and Trauma
23(1): 69-73.
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Hooper, T. L., J. Denton, M. K. McGalliard, J. M. Brismee and P. S. Sizer, Jr. (2010). "Thoracic outlet
syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis." J
Man Manip Ther 18(2): 74-83.
Hooper, T. L., J. Denton, M. K. McGalliard, J. M. Brismee and P. S. Sizer, Jr. (2010). "Thoracic outlet
syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management." J Man
Manip Ther 18(3): 132-138.
Povlsen, B., T. Hansson and S. D. Povlsen (2014). "Treatment for thoracic outlet syndrome."
Cochrane Database Syst Rev 11: Cd007218.
Twaij, H., A. Rolls, M. Sinisi and R. Weiler (2013). "Thoracic outlet syndromes in sport: a practical
review in the face of limited evidence--unusual pain presentation in an athlete." Br J Sports Med
47(17): 1080-1084.
Watson, L. A., T. Pizzari and S. Balster (2009). "Thoracic outlet syndrome part 1: clinical
manifestations, differentiation and treatment pathways." Man Ther 14(6): 586-595.
Watson, L. A., T. Pizzari and S. Balster (2010). "Thoracic outlet syndrome part 2: conservative
management of thoracic outlet." Man Ther 15(4): 305-314.
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