Thoracic Outlet Syndrome

Normal Anatomy Thoracic Outlet: Neurovascular structures: Interscalene triangle Costoclavicular space Subcoracoid Space Neurovascular structures: Brachial plexus Subclavian vein Subclavian artery

Pathophysiology Compression or compromise of brachial plexus, subclavian artery or vein Occurs at any of the 3 spaces in the thoracic outlet

Pathophysiology Symptoms depend upon which structures are compromised Pain Paraesthesia Weakness Discomfort in the upper limb Vascular dysfunction

Mechanism Of Injury Traumatic Insidious Rare Whiplash Fractures Crush injury Insidious Congenial abnormalities Postural Repetitive overuse Soft tissue adaptions

Classification

Associated Pathologies Whiplash Associated Disorder Chronic Obstructive Pulmonary Disease Presence of cervical rib Deformity of first rib Deformity of C7 transverse process Fracture clavicle, sternum or acromioclavicular joint.

Subjective Aged 20-50 years More females than men (ratio from 2:1 and 4:1) Unilateral symptoms Pain Paraesthesia Weakness Change in skin colour and temperature Reduction of arterial pulse Aggravated by sustained shoulder elevation, suspensory holding activities, lying on the arm, carrying a handbag or prolonged postures. Pain wakes them at night

Objective Abnormal posture Restricted and painful ROM Pain on sustained arm elevation Poor scapular positioning at rest and moving Change in skin temperature Change in sensation Change in power Hypermobility or hypermobility of cervical, thoracic or upper limb joints. Tightness and pain on palpation of surrounding soft tissues

Thoracic Outlet Syndrome Cervical Radiculopathy

Special Tests 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 Chest X-Ray with or without angiography (vascular) MRI Ultrasound with Doppler Nerve conduction studies Anterior scalene block

General Management Dependant upon classification Neural Vascular Unlikely to treat vascular, may need onward referral Treatment based on assessment Difficult to treat due to misdiagnosis

Conservative - Management Advice for posture, activity modification, avoiding aggravating factors and pain Reduce pain, swelling and inflammation Medications (opioids, NSAIDs); Ice and or heat; Light soft tissue massage; Taping for postural management Increase Range of Movement Decrease tone Soft tissue massage: paraspinals, scalenes, trapezius, pectoralis minor, pathway of peripheral nerves Diaphragmatic breathing (offloads scalenes) Stretching Light ROM exercises Dry needling Improve Joint Movement Joint mobs: cervical spine, thoracic spine, glenohumeral joint, first rib Soft tissue massage Manipulations Exercise

Conservative Management Restore Normal motor control and strength Deep neck flexors, scapular control and mobility, core stability, shoulder dynamic stability (rotator cuff) Restore dynamic stability and proprioception Strengthen under load, improve scapular mobility throughout range, sport and activity specific

Plan B - Management Dependant upon type of TOS; may need thromboectomy or anticoagulation if vascular Surgery rarely performed Removal of congenital abnormalities Scalene or pec minor release