Thoracic Outlet SyndromeCase Study

Madison Gartman, OTS3/25/13

Thoracic Outlet

• The thoracic outlet provides a pathway for the neural and vascular structures to the UE.

• The borders of the outlet: – first rib (inferiorly), clavicle (superiorly), anterior

scalene muscle (anteriorly), and medial scalene muscle (posteriorly).

Thoracic Outlet Syndrome (TOS)• Neurovascular compression of the subclavian

vessels and the lower trunk or medial cord of the brachial plexus.

• Most commonly occurs at: interscalene triangle, costoclavicular triangle, and subcoracoid space

• Often in women between late adolescence and 50-55yo – Idiopathic TOS predominantly affects adult women

Possible causes of TOS• Anterior scalene tightness

– Compression of the interscalene space between the anterior and middle scalene muscles-probably from nerve root irritation, spondylosis or facet joint inflammation leading to muscle spasm.

• Costoclavicular approximation – Compression in the space between the clavicle, the first rib and the muscular and

ligamentous structures in the area-probably from postural deficiencies or carrying heavy objects.

• Pectoralis minor tightness – Compression beneath the tendon of the pectoralis minor under the coracoid process-may

result from repetitive movements of the arms above the head (shoulder elevation and hyperabduction).

• Symptoms may include: – numbness, tingling, parathesias, muscular weakness, edema, cyanosis (skin discoloration),

coldness, or fatigue in the affected UE.

Evaluation

• Eval for therapy should include an assessment of overall posture and ROM of neck and shoulders. – May consider performing provocative tests; however,

false positives are of concern.

• Therapy should focus on improving the overall balance of the shoulder girdle muscles.– Improving muscle balance leads to lifting of the lower

trunk off the first rib, thereby decreasing pressure from the pectoralis muscle group.

EAST Test or "Hands-up" Test • The patient brings their arms up with elbows

slightly behind the head. • The patient then opens and closes their hands

slowly for 3 minutes. • A positive test is indicated by pain, heaviness or

profound arm weakness/numbness and tingling of the hand.

Adson or Scalene Maneuver • Locate the radial pulse in the tested UE. • The patient rotates their head toward the tested arm

and lets the head tilt backwards (extends the neck) while the examiner extends the arm.

• A positive test is indicated by a disappearance of the pulse.

Costoclavicular Maneuver

• Locate the radial pulse and draw the patient's shoulder down and back as the patient lifts their chest in an exaggerated "at attention" posture.

• A positive test is indicated by an absence of a pulse.– This test is particularly effective in patients who complain

of symptoms while wearing a back-pack or a heavy jacket.

Allen Test • Flex the patient's elbow to 90 degrees while the

shoulder is extended horizontally and rotated laterally.

• The patient is asked to turn their head away from the tested arm.

• The radial pulse is palpated – If pulse disappears as the patient's head is rotated the test

is considered positive.

Provocative Elevation Test Used on patients who already present with symptoms

• The patient sits and the examiner grasps the patient's arms. The patient is passive as the shoulders are elevated forward and into full elevation. – The position is held for 30 seconds or more. – Symptoms include increased pulse, skin color change,

increased hand temperature, numbness to tingling.

Diagnosing TOS

• Controversial due to the similarities with brachial plexopathy.

• True TOS should include:– a component of vascular compression and brachial plexus

compression and/or entrapment. – Vascular presentations are uncommon (3-5%).

• Pts should be instructed on management of the condition. – Reirritation of the injured plexus leads to further scarring and

pathology as a result of inflammatory reaction.

Pt Education

• Most important step: educate the pt on how not to irritate the injured plexus. – Breathing with diaphragm and minimize the use of the scalene

muscles– Safe sleeping positions to avoid stretching or compressing the plexus– Posture control that minimizes stress on the brachial plexus

• If the client is able to follow movement restrictions and plexus irritation drops to a stable level, the client can attempt gliding and stretching exercises to regain plexus mobility. – Plexus mobility improvement will improve ADL function

Intervention• Exercises are begun in the pain-free range.

– Slow/comfortable stretches are important – Heat pack or modalities may be helpful in decreasing pain and/or muscle

spasms. – Diaphragmic breathing

• Once symptoms have improved 80%, strengthening exercises may be initiated. – Strengthen slowly and be “muscle specific” as possible– Strengthening should begin in a gravity eliminated/assisted plane and

progress as tolerated. – Weights/resistance can be added when 25 repetitions of a specific exercise is

tolerated. – Begin decreasing the number of repetitions by 50% as weight tolerance is

increased.

Case Study

• 39yoF

• Worked at Nissan – Line prod for dashboards, headlights

• Received steroid shots for Asthma– June, July, August 2013

• Wt gain of 30#

• Noticed pain-– Neck, LUE shoulder/arm, chest, upper

back

• Swelling began in January 2014

• Visit with Pulliam: February 3

Case Study• Pt reports pain in BUE between 5 and 6

– Heat for pain management

• Noted swelling in BUE

• Pt states episodes of “pulling” through upper back into chest with muscle spasms that are unilateral and travel to opposite UE

• BUE hands are sore and painful

• Pt reports difficulty holding grasping/holding objects, opening bottles, lifting laundry; often drops items

• Pt reports BUE hand numbness during activities such as home mgmt, cooking

Case Study

• HP x 10 minutes prior therapeutic exercises• Scapular retraction/protraction x 30 reps• Bilateral neck stretches x 30 reps• Chin tucks x 30 reps• Pec stretches, arms at side x 30 reps• Postural control• Treadmill x 10 minutes• IFC x 20min with HP on bilateral shoulders

Case Study

Current status • Per Pulliam (3/14): – Spurling’s positive for BUE shoulder pain– BUE weakness in supraspinatus, biceps, wrist

extensors, finger abduction/adduction; – Loss of lordotic curve– Cervical spondylosis/stenosis; TOS

ReferencesButler, M.W. (2007). Common shoulder diagnoses. In Cynthia Cooper

(Ed.), Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (pp. 157-163). St. Louis, MO: Mosby.

Ferrante, M. (2012). The thoracic outlet syndromes. Muscle & Nerve, 45(6), 780-795. doi:10.1002/mus.23235

Nichols, D. & Seiger. (2013). Diagnosis and treatment of a patient with bilateral thoracic outlet syndrome secondary to anterior subluxation of bilateral sternoclavicular joints: A case report. Physiotherapy Theory & Practice, 29(7), 562-571. doi:10.3109/09593985.2012.757684

Nicholas Institute of Sports Medicine and Athletic Trauma. Thoracic Outlet Syndrome. Retrieved March 11, 2014, from http://www.nismat.org/

Simon, N., Ralph, J., Chin, C., & Kliot, M. (2013). Sonographic diagnosis of true neurogenic thoracic outlet syndrome. Neurology, 81(22), 1965. doi:10.1212/01.wnl.0000436621.33155.ed

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