Thoracic Outlet Syndrome

Question 1

Structural Issues

Answer 1

clavicular fracture 
rib fracture 
cervical rib 
elongated transverse process C7 
anomolous fibrous bands

Question 2

Pathophysiology

Answer 2

brachial plexus passes through thoracic outlet before entering the arm
structures can become compromised as passes through
- either structural or functional issues
either neurogenic or vascular

Three areas

• interscalene triangle
• costoclavicular interval
• axillary interval

Question 3

Vascular TOS

Answer 3

compromised arterial or venous supply
typically structural issue 
Symptoms 
- ischaemic pain 
- cold 
- colour change 
- swelling 
- fatigue

Question 4

Neurogenic TOS

Answer 4

True - when nerve is symptomatic and has compromised function
- typically structural issue
requires surgery
Symptomatic - nerve sensitised but functioning
- mainly functional issue
managed conservatively

Question 5

Symptomatic nTOS - symptoms

Answer 5

contralateral neck and shoulder pain 
chest and thoracic pain 
neurogenic arm pain 
arm heaviness
aggs = arm elevation and scapula depression 
intermittent paraesthesia 
weak and clumsy

Question 6

Symptomatic nTOS - signs

Answer 6

nerve conduction tests 
neural tissue sensitivity tests 
special tests 
impaired TO function 
if neural integirity positive = true TOS

Question 7

Causes impaired TO function

Answer 7

increased thoracic flexion 
reduced thoracic extension 
reduced rib 1 movement under caudal load 
excessive scalene activity 
reduced scalene extensibility 
reduced subclavius extensibility 
reduced pec minor extensbility 
poor upper traps capacity

Question 8

Management - movement

Answer 8

open space around the nerve 
promote thoracic extension 
improve extensibility of scalenes 
improve subclavius extensibility 
improve caudal mobility of rib 1 
improve extensibility of pec minor

Question 9

Management - muscle function

Answer 9

minimise closing around the nerve
improve thoracic extensor capacity
decrease use of scalenes
improve upper traps capacity

Question 10

Diagnosis

Answer 10

neurogenic sounding arm pain
distribution behaviour suggests TO
positive TO tests
sure not nerve root pain or complex regional pain syndrome