1. Thoracic Outlet Syndrome (TOS)

2. What will this presentation include
Anatomy, Classification, Signs and Symptoms, Differential diagnosis and evidence based treatment for Thoracic Outlet Syndrome

3. TOS Controversial syndrome affecting the thoracic outlet region
Neurogenic compression?
Vascular compression?
Both? (Demondion et al, 2003)

4. Diagnosis
Accurate diagnosis of TOS is controversial. Unfortunately, there are no pathognomonic signs or symptoms.
Some tests can be done to help determine diagnosis alongside presentation of symptoms
Use of MRI
Pathognomonic – puts disease beyond any doubt

5. MRI - Demondion et al, 2003
RESULTS: Patients with TOS had a smaller costoclavicular distance after the postural maneuver (P < .001), a thicker subclavius muscle in both arm positions (P < .001), and a wider retropectoralis minor space after the postural maneuver (P < .001) than did volunteers. Venous compressions after the postural maneuver were observed in 47% of volunteers and 63% of patients at the prescalene space, in 54% of volunteers and 61% of patients at the costoclavicular space, and in 27% of volunteers and 30% of patients at the retropectoralis minor space. Arterial and nervous compressions, respectively, were seen in 72% and 7% of patients. No arterial or nervous compression was seen in volunteers. Except for venous thrombosis, vasculonervous compressions were demonstrated only with arm elevation. Only three thoracic outlet measurements differed significantly in both populations.
CONCLUSION: MR imaging appeared helpful in demonstrating the location and cause of arterial or nervous compressions.

6. The 3 sites of compression
Interscalene triangle
Costoclavicular space
Sub-coracoid tunnel

8. Classification of TOS Vascular Neural Arterial Venous true
Disputed / non-specific

9. Ninety-four percent to 97% of cases present neurologic symptoms
These patients may complain of paresthesias involving the entire upper extremity. However, most often, paresthesias are in the ulnar nerve distribution (C8,T1)

10. Primary Symptoms Painful paraesthesia: C8, T1 Hand weakness
Unilateral occipitofrontal headache
Anterior deltoid/breast pain
Facial/auricular/dental/TMJ pain
Sensory blunting (asbestos hands)
Weakness is a complaint in as many as 50% of patients. Sometimes pain first sometimes parathesia.
Vascular manifestations of TOS are rare. Venous obstruction may cause edema and cyanosis of the upper extremity. Venous collateralization may result in distended superficial venous channels across the chest and shoulder. Arterial obstruction--the least common form of presentation of TOS--may result in a cool extremity with pallor, aching, or pain that is exacerbated by active use of the limb.

11. Seconadry Symptoms Brachial ischaemia/fatigue (whole hand)
Venous engorgement
Vasospasm – Vasoconstriction
Features of other diagnoses
Illness behaviour

12. Agg’s and Eases Eases Arms by side
Arm elevation (telephone, hairwash, driving)
Repetitive motion
Posture
VDU
Stress
Eases
Arms by side
Scapular elevation (support forearms)
Remove provocation
Analgesia

13. Differential Diagnosis
Pancoast tumour MS
Shoulder pathologies
Cervical & Thoracic pathologies
Rib dysfunction
Myofascial referred
Peripheral nerve entrapments
T4 syndrome

14. Tests Allens Test Adsons Manuvre Roos’ Test
Provactive – disappearance of pulse
Also nerve conduction – dimished ulna nerve conduction rate
EMG of hyperthenar and hypothernar eminence can show chronic denervation

15. Allen’s Test Patient sitting, arm abducted to 90°
Horizontally extend and laterally rotate arm
Disappearance of radial pulse on contralateral rotation is positive sign

16. Adsons Manoeuver
Sitting, rotate head towards testing arm, feel for radial pulse
Patient extends neck while clinician extends and laterally rotates shoulder
Patient takes a deep breath and disappearance of radial pulse is positive

17. Roos’ Test
Sitting, shoulders bilaterally abducted to 90° and externally rotated, elbows at 90°
Open and close hands 15 times (some texts state 3 mins!)
Fatigue, heaviness/weakness, cramping and/or paraesthesia positive signs

18. Treatment Initially conservative unless serious vascular compromise
Options – transcutaneous nerve stimulation, postural re-ed, shoulder girdle strengthening, electrotherpay

19. Treatment and Evidence
Exercise programmes. Peer et al. Aimed at improving shoulder posture
1. Shoulder exercises should be performed with a 2-1b weight in each hand. Shrug shoulders forward and upward. Relax. Shrug shoulders backward and upward. Relax. Shrug shoulders upward again. Relax. Increase weights as tolerated.
2. Begin with arms at sides holding 2-1b weights. Abduct arms until hands meet overhead. Finish exercise with palms facing away from each other. Again, the weight can be increased gradually as tolerated.
3. For neck exercises, bend neck to the left and then to the right trying to touch ear to shoulder. Rest between each attempt.
4. Lie on your stomach with hands behind the back. Inhale while raising head and chest off the floor. Exhale and relax.
5. Lie on the floor, back to ground, with a small pillow between the shoulder blades and no pillow under the head. Inhale and raise arms upward and backward overhead. Return arms to side while exhaling. Each set can be performed 5 to 10 times.

20. Surgical Options
Several Surgical options for releasing structures causing TOS, e.g scalenes, pecs, first rib etc
Complications – pnuemathorax, brachial plexus damage (transient or permanent) hemathorax, plural effusion, injury to sub clav artery (life threatening)
Recurrence of Symptoms

21. Systematic review of treatment
C-n. C Lo et al – Hong Kong Physiotherapy Journal
Evaluated 11 studies in past 20 years
Lack of strength and consistence to make clear decision about treatment of TOS
Four articles found physiotherapy exercises beneficial, two physio plus medication beneficial
Therefore exercise programmes for scapula-thoracic muscles (stretching ant scalene/pec minor/lower traps and strengthen serratus anterior/upper traps and sternocleidomastoid)
Future – longitudianal studies due to low incidence of TOS

22. References
Demondion, X. Bacqueville, E. Paul, C. Duquesnoy, B. Hachulla, E. & Cotton, A. (2003) Thoracic outlet: Assessment with MRI in asymptomatic and symptomatic populations. Radiology, 227(2):
Chi-ngai Lo, C Adly Bukly, S & Simon, J 2011 Systematic Review: the effectivness of physical treatments on thoracic outlet syndrome in reducing clinical symptoms Hong Kong Physiotherapy Journal 29, 53 – 63
Kuschener, S & Flecther J 1996 Thoracic outlet syndrome Diagnosis and treatment Operative techniques in sports medicine 4(1) 2-7

23. Any Questions ?