1. THORACIC OUTLET SYNDROME

2. Outcomes Be familiar with the anatomy and of the thoracic outlet.
Be familiar with the clinical presentation of a patient with typical Thoracic Outlet Syndrome.
Be familiar with the most widely used medical as well as physiotherapy treatment protocols for a patient with typical Thoracic Outlet Syndrome.
Be able to give appropriate exercises and advice to a patient with typical Thoracic Outlet Syndrome.

3. Pathology
The neurovascular structures run from the thorax to the upper extremities through the thoracic outlet
Four specific areas: Superior thoracic outlet
Scalene triangle
Costo-clavicular area
Pathway of the coracoid
pectoralis

5. Symptoms
Will depend on the specific structures – brachial plexus and the subclavical arteries
Symptoms may be neurological, vascular or both
Loss of: Stereognosis
Fine co-ordination
Clumsiness of the hands
Patient complains of swollen hands/hands feel heavy and numb

6. Symptoms (cont) Fingers feel numb/cramps in fingers
Vascular symptoms worsen with elevation of the shoulders and if a heavy object is carried
Neurological symptoms: Nerve root pain
Abnormal sensation
Weakness
Vascular symptoms: Ischaemic pain
Claudication

7. Symptoms (cont) Symptoms may be aggravated by abduction of the arm
Onset of symptoms usually spontaneous but can also follow after trauma to the arm or neck
Neurological signs can be seen with the 3 minute stress test and vascular signs with abduction, extension and lateral rotation during palpation of the radial pulse

8. Symptoms (cont) Add rotation of the head Deep breathing
A positive test shows signs of known pain, reduced pulses and pallor of the hands
NB Remember ULTT

9. Treatment
Conservative treatment except with neurological signs where surgery is indicated
Handling of fear and ignorance
Posture correction
Exercises for the strengthening of the pectoral girdle
Mobilisation of the1st rib, cervical as well as upper and mid thoracic
Triggerpoints in m scaleni and m trapezius
Relaxation exercises

10. Treatment (cont) Stretches of m scaleni and m pectoralis
Advice regarding activities that provoke symptoms: Refrain from carrying heavy objects
Refrain from wearing heavy jackets
Do not let arm hang down while
sleeping
Always keep shoulder slightly
elevated
If there is no improvement – resection of the 1st rib or clavicle (cosmetically unacceptable)