Thoracic outlet syndrome/ TOS

Thoracic Outlet Syndrome

1. THORACIC OUTLET SYNDROME PRESENTED BY: HEMANT AGGARWAL MPT FINAL YEAR (Musculoskeletal Disorders) 1801717120002 Submitted to: DR. SHABNAM JOSHI

2. Introduction : The term ‘thoracic outlet syndrome’(TOS) was coined by RM Peet in 1956 It is simply defined as neurovascular symptoms in the upper extremities due to pressure on the nerves and vessels in the thoracic outlet area The specific structures compressed are usually the nerves of the brachial plexus and occasionally the subclavian artery or vein (Richard J. Sanders)

3. Thoracic outlet: The thoracic outlet has three anatomic compartments Interscalene triangle : bordered anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and inferiorly by the medial surface of the first rib Costoclavicular: lies b/w the clavicle and the first rib posteromedially and the upper border of the scapula posterolaterally Retropectoralis minor spaces: lies inferior to the coracoid process beneath the pectoralis minor tendon

4. Contents: Brachial Plexus Interscalene triangle Subclavian artery Subclavian Vein Costoclavicular Retro- pectoralis minor spaces

5. Etiology: ANATOMICAL DEFECTS: Bony abnormalities- According to Sanders RJ, Hammond SL et al. 2006 Cervical rib Long C7 transverse process Abnormal bands, ligaments Fracture clavicle/first rib Exotosis (bony spur) Tumor

6. Soft-tissue Abnormalities - Variation in scalene origin and insertion Atasoy et. al 2004 , scalenus minimus, an accessory muscle, can be found in 30-50% Hypertrophy of the scalene musculature Congenital anomalous ligaments or bands Trauma and later scarring (Roos DB et. al 1996) costocoracoid ligament is implicated in venous compression in Paget-Schroetter syndrome

7. Classification:   True neurogenic , Arterial, Venous, Traumatic neurovascular, Nonspecific TOS According to Sanders RJ, Hammond SL et al., Neurogenic TOS accounts for more than 90% of all TOS cases, whereas vascular TOS constitutes 3% to 4% of all cases Vascular TOS is seen equally in nonathletic men and women, but neurogenic TOS is three to four times more likely to occur in women than in men

8. Neurogenic TOS:   Symptoms: loss of dexterity, muscle spasm, and a feeling of heaviness of the upper extremity pain or weakness in the dermatomes and myotomes associated with C8 or T1 compression  paresthesias or weakness of the hand and arm, as well as pain involving the head, neck, shoulder, and back cold intolerance, Raynaud phenomenon, coldness of the hand, and color changes as a result of sympathetic overactivity as opposed to ischemia  headaches, tinnitus, and vertigo also may be present

9. Venous TOS:  also known as Paget-Schroetter syndrome caused by a spontaneous thrombosis of the subclavian or axillary vein (mainly in swimming, tennis, and weight lifting) the limb feels heavy and becomes edematous and possibly even cyanotic patient may have neurologic features such as pain and paresthesias because of the vascular insult rather than injury to the nerve itself   Three most important factors :- hypertrophy of the pectoral muscle, fibrosis and thickening of the damaged vessel wall from repetitive activity, damage to the intima of the vein leading to a thrombogenic surface

10. Arterial TOS: the least common form of TOS but may have the most serious potential consequences to life or limb most likely from compression b/w the anterior scalene muscle or a bony anomaly such as a cervical rib or deformed first thoracic rib  Kee et al. reported on ischemia of the throwing hand in professional baseball pitchers because of an embolic occlusion from an axillary artery branch aneurysm  Rohrer et al. showed that the subclavian or axillary artery can undergo considerable compression in arms that were hyperextended into a throwing position    reported at least a 20 mm Hg increase in arterial blood pressure in athletes and nonathletes when the arm was placed in that position

11. Differential Diagnosis:

12. Physical Examination: Gilliatt-Sumner hand , a characteristic finding of neurogenic TOS, is described as atrophy of the abductor pollicis brevis and, to a lesser degree, the hypothenar musculature and the interossei blood pressure difference of 20 mm Hg between the upper extremities is a significant but rare finding of vascular TOS upper extremity and chest wall may be congested and edematous with prominent superficial veins in venous TOS In arterial TOS, the upper extremity may appear pale

13. Distal skin changes, ulcerations, and signs of microembolic events are rare findings. Palpation of the supraclavicular region may reveal tender pain with movements of the neck, shoulder, and upper limb WRIGHT TEST: decrease in the radial pulse with the arm in hyperabduction and external rotation, with the head turned in the opposite direction With this maneuver, the radial pulse dampens or obliterates in up to 7% of the normal population

14. ADSON TEST : bringing the arm into extension turning the head toward the affected side, and taking a deep breath ROOS TEST: the patient places both arms in the 90 abducted position with the elbows flexed to 90 The hands are then opened and closed for a 3-minute period Normal persons may have minor discomfort due to muscular fatigue, but patients with TOS have more dramatic symptoms that replicate their usual discomfort such that they may not be able to complete the test

15. WRIGHT TEST: ADSON TEST:

16. ROOS TEST:

17. Conservative Management: STAGE 1: Focus on patient education, pain control, range of motion, nerve gliding techniques, strengthening and stretching  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  Encouraging diaphragmatic breathing

18. Scapula Settings and Control-  important to establishing normal scapula muscle recruitment and control in the resting position progressed to maintaining scapula control while both motion and load are applied programme begins in lower ranges of abduction progressed to abduction and flexion range with higher ranges of elevation

19. STAGE 2 : Massage Strengthening of the levator scapulae, sternocleidomastoid and upper trapezius Stretching of the pectoralis, lower trapezius and scalene muscles Postural correction exercises Relaxation of shortened muscles  Aerobic exercises in a daily home exercise program

20. Exercises:

21. 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)

22. First Rib mobilization: Posterior GH glide:

23. 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

24. Inferior GH Glide: Anterior GH Glide:

25. Article 1: Acute effects of manual therapy on respiratory parameters in thoracic outlet syndrome Researchers : Melda Sağlam et al. Journal : Turkish Journal of Thoracic and Cardiovascular Surgery 2019 Sample size: 10 subjects Stretching of scalene, upper trapezius, sternocleidomastoid , rectus abdominis , hip flexor muscles mobilization of first rib, cervical and thoracic spine, sacroiliac joints and thorax were applied as manual therapy program Conclusion: A 30-minute single manual therapy session improved inspiratory muscle strength and respiratory muscle endurance but not pulmonary function and expiratory muscle strength in patients with thoracic outlet syndrome

26. Article 2: Comparison between Steroid Injection and Stretching Exercise on the Scalene of Patients with Upper Extremity Paresthesia: Randomized Cross-Over Study Reseachers : Sang Chul Lee et al. Journal : Yonsei Medical Journal(South Korea) 2016, March Sample Size : Twenty patients in two groups Duration : 2 weeks Conclusion : Ultrasound-guided steroid injection or stretching exercise of scalene muscles led to reduced upper extremity paresthesia although injection treatment resulted in more improvements

27. Reference: Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr : Thoracic outlet syndrome: A controversial clinical condition. Part 1: Anatomy, and clinical examination/diagnosis. J Man Manip Ther 2010;18(2): 74-83. Sanders RJ, Hammond SL: Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg 2002;36(1):51-56 . Atasoy E: Thoracic outlet syndrome: Anatomy. Hand Clin 2004;20(1):7-14, v . SandersRJ,HammondSL:Venousthoracic outlet syndrome. Hand Clin 2004;20(1): 113-118, viii . Marine L, Valdes F, Mertens R, Kramer A, Bergoeing M, Urbina J: Arterial thoracic outlet syndrome: A 32year experience. Ann Vasc Surg 2013;27 (8): 1007-1013 L.A. Watson, T. Pizzari ,, S. Balster:Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways. L.A. Watson et al. / Manual Therapy 14 (2009) 586–595 Huang JH, Zager EL: Thoracic outlet syndrome. Neurosurgery 2004;55(4): 897-902, discussion 902-903 . Gilliatt RW, Le Quesne PM, Logue V, Sumner AJ: Wasting of the hand associated with a cervical rib or band. J Neurol Neurosurg Psychiatry 1970;33 (5):615-624 . Gergoudis R, Barnes RW: Thoracic outlet arterial compression: Prevalence in normal persons. Angiology 1980;31(8): 538-541.

28. Klaassen z, Serenson E, Tubbs RS, et al: Thoracic outlet syndrome: A neurological and vascular disorder. Clin Anat 2014;27 (5):724-732 .  Crosby C.A. et al., Conservative treatment for thoracic outlet syndrome., Hand Clinics, 2004, Volume 20(1): 43-9  Hooper T, Denton J, McGalliard M, Brismée J, Sizer P. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. Journal of Manual; Manipulative Therapy. June 2010;18(3): 132-138   Vanti C. et al., Conservative treatment of thoracic outlet syndrome A review of the literature, Europa Medicophysica , 2006, Volume 42 Nicholas A. Levine and Brandon R. Rigby:Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations. Healthcare 2018, 6, 68 Tüzün Fırat , Sağlam , Naciye Vardar Yağlı , Yasin Tunç , Ebru Çalık Kütükçü , Kıvanç Delioğlu et al .: Acute effects of manual therapy on respiratory parameters in thoracic outlet syndrome. Turkish Journal of Thoracic and Cardiovascular Surgery 2019;27(1):101-106 Yong Wook Kim, Seo Yeon Yoon, Yongbum Park, Won Hyuk Chang, and Sang Chul Lee:Comparison between Steroid Injection and Stretching Exercise on the Scalene of Patients with Upper Extremity Paresthesia : Randomized Cross-Over Study. Yonsei Med J 2016 Mar;57(2):490-495