Thoracic outlet syndrome

Thoracic outlet syndrome

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  Thoracic Outlet Syndrome: By:Radhika Chintamani Introduction: Thoracic outlet syndrome is a group of disorders that occur when blood vessels or nerves in the space between your collar bone and your first rib (thoracic outlet) are compressed. This can cause pain in your shoulders and neck and numbness in your fingers. There are three main types:  1. The neurogenic type: is the most common and presents with pain, weakness, and occasionally loss of muscle at the base of the thumb.[1][2]   2. The venous type results in swelling, pain, and possibly a bluish coloration of the arm. 3. The arterial type results in pain, coldness, and paleness of the arm.[2] Anatomy: Anatomically these syndrome can be classified into 3 types depending on the area where the compression occurs: 1. The first narrowing area is the most proximal and is named the interscalene triangle: This triangle is bordered by the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the medial surface of the first rib inferiorly. The brachial plexus and the subclavian artery pass through this space. 2. The second passageway is called the costoclavicular triangle which is bordered anteriorly by the middle third of the clavicle, posteromedially by the first rib, and posterolaterally by the upper border of the scapula. The subclavian vein, artery and brachial plexus crosses this costoclavicular region and then further enters the subcoracoïd space. Just distal to the insterscalene triangle. Compression of these structures can occur as a result of congenital abnormalities, trauma to the first rib or clavicle, and structural changes in the subclavian muscle or the costocoracoid ligament. 3. The last passageway is called the subcoracoid or sub-pectoralis minor space: This last passageway is beneath the coracoid process just under the pectoralis minor tendon. The borders of the thoraco-coraco-pectoral space include the coracoid process superiorly, the pec minor anteriorly, and ribs 2-4 posteriorly. Shortening of the pectoralis minor can lead to a narrowing of this last space and therefore compression of the neurovascular structures during hyperabduction. Epidemiology: Evidence: Study stated that TOS affects woman 3-4times than men between the age of 20 and 50 years. Females have less-developed muscles, a greater tendency for drooping shoulders owing to additional breast tissue, a narrowed thoracic outlet and an anatomical lower sternum, these factors change the angle between the scalene muscles and consequently cause a higher prevalence in women. Evidence: A study stated in conclusion that among 20 subjects with TOS, 15 had brachial plexus injury. (95-98%); the other 2-5% affecting vascular structures, such as the subclavian artery and vein.  Causes: Cervical ribs are present in approximately 0.5-0.6% of the population, 50-80% of which are bilateral, and 10-20% produce symptoms; the female to male ratio is 2:1. Cervical ribs and the fibromuscular bands connected to them are the cause of most neural compression. Fibrous bands are a more common cause of TOS than rib anomalies. TOS may result from trauma, repetitive arm movements, tumors, pregnancy, or anatomical variations such as a cervical rib. The diagnosis may be supported by nerve conduction
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  studies and medical imaging. Otherconditions that can produce similar symptoms include rotator cuff tear, cervical disc disorders, fibromyalgia, multiple sclerosis, and complex regional pain syndrome.[1] Certain anatomical abnormalities can be potentially compromising to the thoracic outlet as well. These include the presence of a cervical rib, congenital soft tissue abnormalities, clavicular hypomobility [2], and functionally acquired anatomical changes [3]. Soft tissue abnormalities may create compression or tension loading of the neurovascular structures found within the thoracic outlet (such as hypertrophy , a broader middle scalene attachment on the 1st rib or fibrous bands that increase the stiffness,…). Congenital factors Acquired Muscular Systemic Cervical rib Prolonged transverse process Anomalous muscles  Fibrous anomalies (transversocostal, costocostal) Abnormalities of the insertion of the scalene muscles [4] Fibrous muscular bands[4]  Exostosis of the first rib  Cervicodorsal scoliosis[11]  Congenital uni- or bilateral elevated scapula  Postural factors Dropped shoulder condition  Wrong work posture  Heavy mammaries  Trauma to clavicle or first rib Clavicle fracture Rib fracture Hyperextension neck injury, whiplash  Repetitive stress injuries Hypertrophy of the scalene muscles  Decrease of the tone of the trapezius, levator scapulae, rhomboids  Shortening of the scalene muscles, trapezius, levator scapulae, pectoral muscles  Pancoast’s Syndrome  Radiation induced brachial plexopathy  Parsonage Turner Syndrome [2][3] There are conditions that can coexist with TOS, like: carpal tunnel syndrome  peripheral neuropathies (like ulnar nerve entrapment at the elbow, shoulder tendinitis and impingement syndrome)  fibromyalgia of the shoulder and neck muscles  cervical disc disease (like cervical spondylosis and herniated cervical disk)  Characteristics/Clinical Presentation Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. a. Pain anywhere between the neck, face and occipital region or into the chest, shoulder and upper extremity. b. Paresthesia in upper extremity: altered or absent sensation, weakness, fatigue, a feeling of heaviness in the arm and hand. c. The skin can also be blotchy or discolored. d. A different temperature can also be observed. e. When the upper plexus (C5,6,7) is involved there is pain in the side of the neck and this pain may radiate to the ear and face. f. Patients with lower plexus (C8,T1) involvement typically have symptoms which are present in the anterior and posterior shoulder region and radiate down the ulnar side of the forearm into the hand, the ring and small fingers. [24][2]
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  Signs and symptomsare typically worse when the arm is abducted overhead and externally rotated with the head rotated to the same or the opposite side. As a result activities such as overhead throwing, serving a tennis ball, painting a ceiling, driving, or typing may exacerbate symptoms. There are four categories of thoracic outlet syndrome and each presents with unique signs and symptoms. Typically TOS does not follow a dermatomal or myotomal pattern unless there is nerve root involvement. Differential Diagnosis: a.  Complex regional pain syndrome (CRPS I or II).  b. Horner’s Syndrome c. Raynaud’s disease  d. Cervical disease (especially discogenic)  e. Brachial plexus trauma f. Systemic disorders: inflammatory disease, esophageal or cardiac disease g. Upper extremity deep venous thrombosis (UEDVT), Paget-Schroetter syndrome  h. Rotator cuff pathology  i. Glenohumeral joint instability j. Nerve root involvement  k. Malignancies (local tumours) l. Chest pain, angina m. Vasculitis n. Sympathetic-mediated pain. Outcome measures: DASH (Disability of Arm Shoulder and Hand) SPADI (Shoulder Pain And Disability Index) NPRS (Numeric Pain Rating Scale) McGill Pain Questionnaire[2]
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  Special tests:  ElevatedArm Stress/ Roos test: the patient abducts arms at 90° and the therapist puts downwards pressure on the scapula as the patient opens and closes the fingers. If the TOS symptoms are reproduced within 90 seconds, the test is positive.  Adson's: the patient is asked to rotate the head and elevate the chin toward the affected side. If the radial pulse on the side is absent or decreased then the test is positive, showing the vascular component of the neurovascular bundle is compressed by the scalene muscle or cervical rib.  Wright's: the patient’s arm is hyper abducted. If there is a decrease or absence of a pulse on one side then the test is positive, showing the axillary artery is compressed by the pectoralis minor muscle or coracoid process due to stretching of the neurovascular bundle.  Cyriax Release: the patient is seated or standing. The examiner stands behind patient and grasps under the forearms, holding the elbows at 80 degrees of flexion with the forearms and wrists in neutral. The examiner leans the patient’s trunk posteriorly and passively elevated the shoulder girdle. This position is held for up to 3 minutes. The test is positive when paresthesia and/or numbness (release phenomenon) occurs, including reproduction of symptoms. (Hooper et. al., 2010 & Brismee et. al., 2004)  Supraclavicular Pressure: the patient is seated with the arms at the side. The examiner places his fingers on the upper trapezius and thumb on the anterior scalene muscle near the first rib. Then the examiner squeezes the fingers and thumb together for 30 seconds. If there is a reproduction of pain or paresthesia the test is positive, this addresses compromise to brachial plexus through scalene triangles. (Hooper et al., 2010)  Costoclavicular Maneuver: this test may be used for both neurological and vascular compromise. The patient brings his shoulders posteriorly and hyperflexes his chin. A decrease in symptoms means that the test is positive and that the neurogenic component of the neurovascular bundle is compressed. [24]  Upper Limb Tension: These tests are designed to put stress on neurological structures of upper limb. The shoulder, elbow, forearm, wrist and fingers are kept in specific position to put stress on particular nerve (nerve bias) and further modification in position of each joint is done as "sensitizer". (http://www.physio-pedia.com/Neurodynamic_Assessment)  Cervical Rotation Lateral Flexion: The test is performed with the patient in sitting. The cervical spine is passively and maximally rotated away from the side being tested. While maintaining this position, the spine is gently flexed as far as possible moving the ear toward the chest. A test is considered positive when the lateral flexion movement is blocked.
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  PT Rx forTOS: Conservative management should be the first strategy to treat TOS since this seems to be effective at decreasing symptoms, facilitating return to work and improving function, but yet a few studies have evaluated the optimal exercise program as well as the difference between a conservative management and no treatment. Treatment is directed towards the specific stage of TOS: Stage 1: Controlling stage: Aim: decrease the patient’s symptoms . This may be achieved by patient education, in which TOS, bad postures, the prognosis and the importance of therapy compliance are explained. Furthermore some patients who sleep with the arms in an overhead, abducted position should get some information about their sleeping posture to avoid waking up at night. These patients should sleep on their uninvolved side or in supine, potentially by pinning down the sleeves. The Cyriax release test may be used if a ‘release phenomenon’ is present. This technique completely unloads the neurovascular structures in the thoracic outlet before going to bed. Cyriax release maneuver - Elbows flexed to 90°  - Towels create a passive shoulder girdle elevation  - Supported spine and the head in neutral  - The position is held until peripheral symptoms are produced. The patient is encouraged to allow symptoms to occur as long as can be tolerated up to 30 minutes, observing for a symptom decrease as time passes. [17] Level of evidence 2B Also cervical traction in combination with a hot pack and light exercise may reduce pain and irritable symptoms for some acute patients. Level of evidence 2B Breathing technique: Encouraging diaphragmatic breathing will lessen the work load on already overused or tight scalenes and can possibly reduce symptoms. [17] Level of evidence 2B Stage 2:  Treating stage: Aim: is to directly address the tissues that create structural limitations of motion and compression. Methods of Rx: a. Massage. b. Stretching of the pectoralis, lower trapezius and scalene muscles  = These muscles close the thoracic outlet c. Strengthening of the levator scapulae, sternocleidomastoid and upper trapezius = This group of muscles open the thoracic outlet by raising the shoulder girdle and opening the costoclavicular space d. Postural correction exercises  e. Relaxation of shortened muscles [36] Level of evidence 1A f. Aerobic exercises in a daily home exercise program: [36] Level of evidence 1A, [38] Level of evidence 2B 1) Shoulder exercises to restore the range of motion and so provide more space for the neurovascular structures. Exercise: Lift your shoulders backwards and up, flex your upper thoracic spine and move the shoulders forward and down. Then straightened the back and repeat 5 to 10 times.
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  2) ROM ofthe upper cervical spine  Exercise: Lower your chin 5 to 10 times against your chest, while you are standing with the back of your head against a wall. The effectiveness of this exercise can be enlarged by pressing the head down by hands. 3) Activation of the scalene muscles are the most important exercises. These exercises help to normalize the function of the thoracic aperture as well as all the malfunctions of the first rib.  Exercises:  - Anterior scalene: Press your forehead 5 times against the palm of your hand for a duration of 5 seconds, without creating any movement.  - Middle scalene: Press your head sidewards against your palm. - Posterior scalene: Press your head backwards against your palm. 4) Stretching exercises • Taping: some patients with severe symptoms respond to additional taping, adhesive bandages or braces that elevate or retract the shoulder girdle.[15] Level of evidence 1C, [36] Level of evidence 1A • Manipulative treatment to mobilize the first rib Could provoke irritation and pain symptoms in some patients [36] Level of evidence 1A • Repositioning/mobilization of the shoulder girdle and pelvis joints: cervicothoracic, sternoclavicular, acromionclavicular, and costotransverse joints [36] Level of evidence 1A, [17] Level of evidence 2B • Glenohumeral mobilizations in end-range elevation with the elbow supported in extension [38] Level of evidence 2B A) Posterior Glenohumeral Glide with Arm Flexion:  The patient is supine. The mobilizisation hand contacts the proximal humerus avoiding corocoid process. The force is directed posterolaterally (direction of thumb). B) Anterior Glenohumeral Glide with Arm Scaption:  The patient is prone. The mobilization hand contacts the proximal humerus avoiding acromion process. The force is directed anteromedially. C) Inferior Glenohumeral Glide:  The patient is prone. The stabilizing hand holds the proximal humerus the humerus distal to the lateral acromion process. The mobilization hand contacts the axillary border of the scapula. Mobilize the scapula in a craniomedial direction along the ribcage. [17] Level of evidence 2B  First Rib Mobilization: Patient seated. Thin sheet strap positioned around first rib. Pull strap towards opposite hip. Neck retracted, contralateral lateral flexion, and ipsilateral rotation. Ipsilateral head rotation emphasizes scalene stretch. Contralateral rotation emphasizes rib mobilization.  Posterior Glenohumeral Glide with Arm Flexion: Patient supine. Mobilizing hand contacts proximal humerus avoiding corocoid process. Force is directed posterolaterally (direction of thumb).  Anterior Glenohumeral Glide with Arm Scaption: Patient prone. Mobilizing hand contacts proximal humerus avoiding acromion process. Force is anteromedially.  Inferior Glenohumeral Glide: Patient prone. Stabilizing hand holds proximal humerus. Mobilizing hand contacts axillary border of scapula. Mobilize scapula in craniomedial direction along ribcage. Post-Op Physical Therapy[3] If a patient does require surgery, then physical therapy should follow immediately to prevent scar tissue and return the patient to full function.