Thoracic Outlet Syndrome and Physiotherapy Management

Thoracic Outlet Syndrome and Physiotherapy Management, definition, anatomy, Classification, etiology, Clinical feature, Diagnostic Test, 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), Investigation, Physiotherapy, management, Exercise, Serratus anterior,

1. Thoracic Outlet Syndrome Dr. Anand vaghasiya(PT)

2. 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.

3. Types of 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

4. 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

5. Interscalene triangle Most commonly Involved This Space is Bordered medially 1 st 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.

6. 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 1 st 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.

7. 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 2 nd to 4 th . Shortening of Pectoralis major can lead to compression and Narrowing of space. Which is seen in hyper abduction of GH joint.

8. 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

9. X-Ray Showing Extra Rib

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

11. 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.

12. 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.

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

14. Diagnostic Measures

15. 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

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

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

24. 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.

25. 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.

26. 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.

27. 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

28. 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.

29. Exercise Shoulder exercises to restore the range of motion and so provide more space for the neurovascular structures. Exercise Shoulder Flexion Abduction extension exercise. 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. 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.

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

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