THORACIC OUTLET SYNDROME John Broussard, DO Sports Medicine Fellow Institute for Non-Surgical Orthopedics Larkin Community Hospital

Definition • A group of syndromes in which biomechanical

obstructions are believed to compress or obstruct structures in the thoracic outlet

• Subclavian artery & vein • Axillary artery • Cords of brachial plexus

TOS Symptoms • Arterial

• Numbness of arms/hands • Tingling of arms/hands • Positional weakness • Discoloration (pale/white hands)

• Venous • Swelling of fingers and hands • Heaviness of UEs • Discoloration (blue)

• Nerves • UE pain • Paresthesias of ulnar distribution • Weakness of hands • Clumsiness of hands • Coldness of hands • Tiredness, heaviness and

paresthesias on elevation of UEs

• Shoulder and Neck • Pain • Tightness

• Chest Wall • Anginal chest pain (heavy or

squeezing in midsternal area of chest)

• Inter/para-scapular pain (along medial shoulder blade)

• Head • Headaches • “funny feelings” in face and ear

• Vertebral Artery • Dizziness • Lightheadedness

Anatomy • Thoracic outlet? • Borders

• Anteriorly: manubrium • Posteriorly: Body of T1 • Laterally: 1st and 2nd ribs (and their costal cartilage)

• Articulations • Acromioclavicular • Sternoclavicular

Anatomy • “Sibson’s Fascia” = cervico-thoracic fascia

• Runs from root of neck lower boundary of axilla • (TP C7-border of rib 1)

• Tightly confines the neurovascular supply to the arm • Great lymph channels (ascending and descending terminal ducts)

pass through Sibson’s fascia.

Anatomy • Neurovascular bundle

• Subclavian a. (b/w 1st rib and scalenes) • Subclavian v. (anterior to anterior scalene) • Brachial plexus (C5-T1) (more post. and lateral to subclavian a.)

Innervation • Sympathetic

• Brachial plexus (C7-T1): shoulder girdle and upper extremity • T1-T4: head, neck & brain • T1-T8: upper extremity • T1-T6: heart & lungs

• Parasympathetic • Vagus: heart, lungs, upper GI, kidneys

Etiology • All TOSs occur due to a disruption or alteration of the

normal anatomy of the thoracic outlet. • Symptoms of TOS are DIRECTLY related to the structures

disrupted: • Shoulder or arm pain • Weakness • Paresthesias • Claudication • Raynaud’s phenomenon • Ischemic tissue loss • Gangrene

Predisposing Factors to TOS • Intrinsic:

• Anterior scalene tightness • Nerve root irritation, spondylosis, facet joint inflammation muscle spasm

• Pectoralis minor tightness • Repetitive overhead activity (shoulder elevation & hyperabduction)

• Costoclavicular approximation (b/w clavicle, 1st rib, support structures) • Postural deficiencies or carrying heavy objects

• Cervical ribs • Slender body habitus

• Extrinsic • Trauma (contusion, hematoma, clavicular fx, whiplash) • Unusual sleeping positions • Occupations w/ unusual arm postures

• Painters, mechanics, military recruits, backpackers, students • Athletes

• Swimmers, baseball pitchers, volleyball players, tennis players

Compression of neurovascular bundle • 3 locations:

• b/w anterior and middle scalenes • b/w clavicle and 1st rib • b/w pectoralis minor and upper ribs

DDx of TOS • Cervical nerve root compression (radiculopathy) • Pancoast Tumor (lung apex reaches 2/3 cm into neck) • Simple SD of ribs, clavicles, cervicals, thoracic spine • Neurofibromas • Cervical spondylosis • Cervical disc herniation • Carpal tunnel syndrome

• **Any/all may coexist w/ TOS**

Provocative Tests for TOS • Adson’s Test (b/w scalenes) • Costoclavicular (Military posture) test (b/w clavicle & 1st rib) • Hyperabduction test (under pectoralis minor) • Roos Test (Elevated Arm Stress Test)

• ER shoulders, elbows behind head. Open/close hands slowly x3 min. • Pos: pain, heaviness or profound arm weakness or tingling/numbness

• Spurling Test (not specific for TOS)

Adson’s Test Costoclavicular Test Roos Test

Treatment Overview • Protocol

• Identify type and cause of compression • Optimize normal function and treat all somatic dysfunction

• Suggestions • Exercise—stretching program • Correct biomechanics—assess daily life movements of patient

• “Why now?” • Meds: muscle relaxants, NSAIDs, Botox • Biofeedback • OMT • Massage • Physical Therapy • Yoga

Treatment: OMT • Myofascial release of thoracic outlet • Normalize vertebral SD (C2-C7 and upper thoracics) • Upper ribs (1st rib superior subluxation w/ shortening of

scalene muscles) • Appendages (SC, AC, GH) • Lymphatic treatment increase lymph flow • TPIs • Spray and stretch • Acupuncture

OMT • Upper Thoracic HVLA

• Chin pivot thrust • Dysfunction: T1 FRLSL • Patient in prone position w/ chin on table • Stand at head of patient, opposite to posterior

TP. • Place left hypothenar eminence on left TP of T1. • With right hand, SB pt’s head to the right to max

tissue tension while maintaining chin on table. • Rotate head away to obtain max tissue tension. • During exhalation, apply HVLA thrust w/ left hand

directed anteriorly, laterally, and inferiorly while stabilizing the head w/ right hand.

• Recheck.

OMT • SD: 1st Rib inhalation

• Still Technique • Patient supine. • Standing at side of patient on side of dysfuntion. • Flex pt’s elbow and place their palm on chest. • Place pads of index finger on pt’s 1st rib. • Using opposite hand, grasp the elbow and apply

longitudinal compression through humerus. • Using the elbow as a lever, pt’s arm is circumducted

clockwise by moving UE medially until elbow lines up w/ head of pt’s 1st rib.

• The arc of motion from this position is lateral and inferior, continuing circumduction motion, and compression, w/ patient’s arm ending at the midaxillary line.

• Recheck.

OMT • Anterior & Middle Scalenes

• O: TP C2-C7 • I: 1st Rib • A: Flexion and sidebending of C-spine

• Counterstrain • Find the tender point, wrap around it. • Hint: Follow the action of the muscle. • Hold until tissues relax, passively return to resting. • Recheck. • May add traction and passively return to rest (Still)

if no improvement.

OMT

• Pectoralis minor muscle • O: Anterior surface ribs 3-5 • I: Via tendon to medial aspect of coracoid

process of scapula. (Part or all of tendon may transverse this process and continue into coracoacromial ligament)

• A: Scapula protraction, rotation of scapula downwards

• Counterstrain • Find the tender point, wrap around it. • Hold until tissues relax, passively return to

rest. • Recheck.

OMT • Cervicles

• Whichever you are comfortable with or patient (or tissues) will allow: • Counterstrain • Still’s • HVLA

• Caution against muscle energy

Treatment • Self-Stretching

• Scalenes and pectoral muscles • Hold 30 sec., 10 reps bid • WILL exacerbate symptoms • Pain (deep ache) should not persist after stretch released • Strengthening exercises for trapezius and levator scapulae

• Massage • Cross-friction (pec minor and scalenes) • Shoulder girdle

References • DiGiovanna E, Schiowitz S. An osteopathic approach to diagnosis and

treatment. Philadelphia; JB Lippincott Co, 1991:45-53. • Kai Y, Oyama M, Kurose S, et al. Neurogenic thoracic outlet syndrome in

whiplash injury. J Spinal Disord 2001;4:487-493. • Karageanes S. Principles of Manual Sports Medicine. LWW, 2005: 268-293. • Kulund DN. The injured athlete, 2nd ed. Philadelphia: JB Lippincott Co 1988.