Thoracic Outlet Syndrome and Physiotherapy Management

Thoracic Outlet Syndrome
DR. ANAND VAGHASIYA(PT)

Thoracic Outlet Syndrome (TOS)
 Thoracic outlet syndrome is Neurovascular symptoms in the upper limb due to compression
on the nerves and blood vessels in the thoracic outlet area.
The term was coined in 1956 by RM Peet.
Most common Misdiagnosed or undiagnosed Condition.
The specific Structure compressed are usually The Nerve Bundle which is Brachial plexus and
occasionally the subclavian artery or subclavian vein.
Subclavian
vein
Subclavian
artery
Brachial
Plexus

Types of TOS
True TOS
95%
4% 1%
Sales
Neurological TOS
Venous TOS
Arterial TOS
Depending upon exact site (structure )
OR injury (functional) TOS is divide into
three subgroup.
Which is,
Neurological TOS
Arterial TOS, in this
Venous TOS
Arterial TOS

Anatomy Involved
The anatomy of the thoracic
outlet is defined by the bony
circle of the sternum in front,
connected to the first rib laterally,
which attaches to the vertebra
posteriorly. The clavicle attaches
to the first rib and sternum
anteriorly.
 it Consist of three spaces.
Interscalene triangle space
Costoclavicular Space
Pectoralis Minor space

Interscalene triangle
Most commonly Involved
 This Space is Bordered medially 1st rib ,
Anteriorly Clavicle and scalenus Anterior and
posteriorly by Scalenes medius.
Anterior and middle scalene muscles have their
insertion in the first rib.
The brachial plexus and Subclavian artery passes
through this space.

Costoclavicular Space/ triangle
 involvement is Common but majorly seen as
progression of scalene triangle( or left untreated)
The space is bordered by anteriorly by Middle third of
Clavicle and subclavius Muscles, Posteromedial wall is
formed by 1st rib and posterolateral aspect is covered by
superior border of scapula.
The subclavian Vein, artery and brachial Plexus Passes
through this space and enter into subcorocoid space.
Congenital abnormalities, trauma to clavicle or first rib
and postural changes in subclavian muscle can cause
compression of structure passing by.

Subcorocoid Space/ Pectoralis minor space
 Last passage, just beneath the coracoid process just under
Pectoralis minor tendon.
The border contains superiorly by Coracoid process
superiorly, Anteriorly by Pectoralis minor and posteriorly by
Ribs 2nd to 4th.
Shortening of Pectoralis major can lead to compression and
Narrowing of space. Which is seen in hyper abduction of GH
joint.

Etiology/ Causes
Bony Abnormality like Cervical extra rib, Long C7 transverse process, tight bands or ligament or
exostosis(osteoma- benign growth of bone). Clavicle hypermobility.
Tumors
Muscle Abnormality, Anomalous insertion of Scalene, Hypertrophy, Brachial plexus Pass
through muscles, a broaden insertion of Middle scalene on the first rib.
Trauma like Whiplash Injury
Posture, Forward Head posture or Depressed shoulder.
RSI, Typing, swimming or in sport.
Obesity

Clinical Features
Neurogenic TOS
 Paresthesia
Pain in shoulder, arm, forearm and fingers
Occipital headache
Weakness of UE.

Neurogenic TOS
Cervical outlet or Upper thoracic outlet Syndrome
Upper nerve roots of C5, C6 and C7 is affected/ compressed
Lower TOS
In costoclavicular space lower roots like C8 and T1 is compressed.

Arterial TOS
Weakness
Numb or cold limbs
Claudication
In Progressive stage gangrene or Thrombosis which
leads to several Disease like Raynaud's discoloration in
UE genraly in distal area.
Raynaud’s Discoloration in distal UE.

Venous TOS
Edema
Cyanosis
Venous distension
Paget-schroetter syndrome-
uncommon DVT
Cynosis Paget-Schroetter
Syndrome- UE DVT due to
obstruction in subclavian
vein.

Special test
Roos Test/ Elevated arms stress test
Adson maneuver
Wright’s Test Or maneuver
Shoulder Girdle Passive Elevation/ Cyriax Release
Costoclavicular syndrome test/ Military brace Test
Provocative Elevation test
Halsted maneuver
ULTT
Test Sensitivity Specificity
Elevated Arm
Stress
52-84% 30-100%
Adson's 79% 74-100%
Wright's 70-90% 29-53%
Cyriax Release NT 77-97%
Costoclavicular
Maneuver
NT 53-100%
Upper Limb
Tension
90% 38%
Cervical Rotation
Lateral Flexion
100% NT

Adson Maneuver
One of the most common test of TOS
The examiner locates the Pulse.
Rotates head towards affected/test side
shoulder.
Then ask patient to extend head while Therapist
laterally rotates and extends the patient’s
shoulder.
The patient is instructed to deep breathe and
hold it.
Positive Test: Disappereance of Pulse.

Military Brace test
The Examiner palpates the radial pulse and
then drwas patients shoulder down and back.
A Positive test Indicates Absense of Pulse.
Effective on patient who carry heavy bagpack
or coat.

Roos test /Elevated Arm Stress Test
Also known As Positive abduction and external Rotation(AER)
, the Hands up test and EAST.
The patient stands and abducts the arm to 90*
Laterally rotates the shoulder and flexes elbow to 90*
So that elbow are slightly behind the frontal plane.
The patient open-close hand slowly for 3 minutes.
If the patient is unable to keep the arms in the starting
position for 3 minutes or suffers from ischemic pain, heaviness
or profound weakness of the arm or numbness and tingling of
hand during the 3 minute, the test is considered as positive.
Minor fatigue and distress is common and taken as Negative
test.

Provocative Elevation test
Modification of Roos Test.
The patient elevates both arms above the horizontal and is asked to rapidly open and close the
hands fifteen times.
If fatigue, cramping or tingling occurs during the test, the test is Positive for vascular
insufficiency and TOS.

Halsted maneuver
 The examiner finds the radial pulse and
applies a downward traction on the test
exteremity.
While the patients neck is hyper extended
and head is rotated to the opposite side.
Absense or disappearance of pulse is
indicate positive test for TOS.

Shoulder Girdle Passive Elevation Test
This test is used on patient who alredy present
with symptoms. Also known As Cyriax Release test.
Patient sit, examiner grasp elbow from back and
passively elevates shoulder girdle up and forward
into full elevation- a passive bilateral shoulder
shrug.
Release Phenomenon, From Numbness to pins and
needles or tingling with some pain as the nerve
releases from ischemia.
Arterial relief is evidenced by stronger pulse, skin
color change and increased temperature.
Venous relief is shown by decreased cyanosis and
venous engorgement.

Wright Test or Maneuver
 palpate the Radial pulse, Hyper abduct shoulder
with lateral rotation. Test can vary in siting and
supine as well as with holding breathe.
This test is used to detect costoclavicular
compression.
Modification- Allen maneuver: examiner flexes
the patients elbow to 90* while the shoulder is
extended horizontally and rotated laterally.
The patient then rotates the head away from the
test side.
Absense of radial pulse Is indication of Positive
test.

Differential Diagnosis
CTS
Spinal canal tumors
Epicondylitis
Angina Pectoris- Red flag
Raynaud's disease
Shoulder myositis
Cervical IVDP
Cervical Myelopathy

Investigation
X-ray: Degeneration, extra rib, elongated c7 transverse process
USG & Color Doppler: highly sensitive test for Venous stenosis or occlusion, may show
increased flow velocity in the subclavian artery at the site of stenosis.
MRI, Ct : Arterial compression and muscle structure compression artery vein or nerve.
Vascular imaging: Arteriography or venography may show presence of extrinsic compression.
NCV EMG: Sensory potential and motor Potential is reduced out of the proportion of the
median nerve.

Treatment
Conservative
Non conservative/ surgical: If symptoms persist with non operative treatment. Associated
vascular compression. PROGRESSION OF SYMPTOMS, Nerve Conduction velocity is less than
60m/s.
Followed by post Operative Physical therapy for scar Mobilization and Regain ADL without error.

Physiotherapy Management
Goals:
Pain Control and Decrease symptoms of TOS
Facilitating return to work and improving function.
Postural correction
Patient education
Overcome weakness by stretching tight structure and strengthen the weak muscles.

Stage 1
Ice pack in starting of exercise and ending of exercise.
TENS to relive pain
Correction of sleeping and working posture ( Reeducation)
Breathing technique: diaphragmatic breathing will lessen the work load on scalene muscles.
Neural glide of affected Nerve. ( tested by ULTT)
Scapular setting exercise
Serratus anterior Recruitment

Stage 2
Remove structural limitation by soft tissue manipulation or ART.
Stretching and Strengthening of levator scapulae, sternocleidomastoid and Upper trape.
Closing muscle of TO like Pectoralis, lower trape and scalene stretching.
Postural correction
Cervical isometric exercise
Home Program: Icepack and Breathing and Cervical Protraction retraction exercise.

Exercise
1.Shoulder exercises to restore the range of motion and so provide more space for the neurovascular
structures.
Exercise Shoulder Flexion Abduction extension exercise.
2.ROM of the 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. Or Passive Cervical Isometric.
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 are 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.
Patient in Side lying, affected side in upward. Ask patient to turn the head and lift up.

“Act as if what you do makes difference, it does.”
Thank you

Reference:
1. Understanding Thoracic outlet Syndrome, Julie freishlag and Kristine Orion.
2. Orthopedic Physical Assessment, David J. Magee
3. Thoracic Outlet Syndrome: Biomechanical And Exercise Consideration, Nicholas A Levine and
Brandon R. Rigby
4. Thoracic outlet syndrome: A comprehensive Review of Pathophysiology, Diagnosis and
treatment. Mark R. Jones, Amit Prabhakar and Alan D. Kaye
5. Thoracic outlet syndrome: Definition, aetiological factors, diagnosis, management And
occupational impact.

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