Thoracic Outlet Syndrome

Question 1

What is Thoracic Outlet Syndrome (TOS)?

Answer 1

A complex of signs and symptoms resulting from the compression of the neurovascular bundle (NB) as it emerges from the thorax and enters the upper limb.

Question 2

What is required for thoracic outlet tests to be considered positive?

Answer 2

The tests must decrease the pulse and reproduce the patient’s symptoms. These tests have low reliability.

Question 3

What structures are included in the neurovascular bundle?

Answer 3

• Brachial plexus
• Subclavian vein
• Subclavian artery

Question 4

Trace the path of the brachial plexus.

Answer 4

Originates at C5-T1, enters between anterior scalene and middle scalene, passes under the clavicle, over the 1st rib, under the coracoid process, and posterior to pectoralis minor.

Question 5

What are the possible causes of TOS?

Answer 5

1. Cervical rib
2. Reduced interscalene triangle
3. Decreased costoclavicular space
4. Decreased costocoracoid space
5. Decreased space due to shoulder droop
6. Callus formation from a clavicular fracture

Question 6

What primary complaint questions should you ask in a TOS case history?

Answer 6

• Where is the pain?
• Where are the neurological symptoms?
• Is there a specific nerve pattern?

Question 7

What general health factors should you consider in a TOS case history?

Answer 7

Consider factors that might compromise the neurovascular bundle, such as crutch use (crutch palsy).

Question 8

What additional questions are relevant for a TOS case history?

Answer 8

• Mechanism of injury (MOI): Consider injuries to the shoulder, cervical spine, elbow, or wrist.
• Previous injuries: Include dislocations, cervical issues, or shoulder issues.
• Pattern of neurological symptoms.
• Dominant hand (often has greater range of motion).

Question 9

What landmarks should be observed for TOS?

Answer 9

• Head of humerus alignment with the acromion.
•IR (Internal Rotation).
• Clavicle position.
• First rib orientation.
• Tipping.
• General upper body landmarks.

Question 10

What should you palpate for in a TOS assessment?

Answer 10

• Inflammation.
• Swelling.
• Increased resting muscle tension.

Question 11

What regions should you rule out in a TOS assessment?

Answer 11

• Cervical spine.
• Shoulder.
• Thoracic spine.
• Elbow.

Question 12

Are there specific functional tests for TOS?

Answer 12

No, there are no specific functional tests for TOS. Use cervical spine or shoulder ROM based on the primary concern.

Question 13

What is the procedure for Adson’s Maneuver?

Answer 13

1. Palpate the radial pulse on the side being tested.
2. Slightly extend the shoulder and apply downward traction.
3. Ask the patient to take a deep breath and hold it while actively extending and ipsilaterally rotating their neck.

Positive sign: Diminishment of pulse and reproduction of signs and symptoms.

Question 14

What is the procedure for Travell’s Variation/Halstead Maneuver?

Answer 14

1. Palpate the radial pulse on the side being tested.
2. Slightly extend the shoulder and apply downward traction.
3. Ask the patient to take a deep breath and hold it while actively extending and contralaterally rotating their neck.

Positive sign: Diminishment of pulse and reproduction of signs and symptoms.

Question 15

What is the procedure for the Costoclavicular Syndrome Test/Military Stance?

Answer 15

1. Palpate the radial pulse on the side being tested.
2. Ask the patient to stand with shoulders down and back in an exaggerated military stance.
3. Instruct the patient to take a deep breath.

Positive sign: Diminishment of pulse and reproduction of signs and symptoms.

Question 16

What is the procedure for Wright’s Hyperabduction Test?

Answer 16

1. Palpate the radial pulse on the side being tested.
2. Ask the patient to take a deep breath and hold it.
3. Passively fully abduct the patient’s arm (do not allow elevation).

Positive sign: Diminishment of pulse and reproduction of signs and symptoms.

Question 17

What is the procedure for the Roos Test/Elevated Arm Stress Test?

Answer 17

1. Patient is seated or standing with both arms at 90 degrees of shoulder abduction and external rotation.
2. Patient actively brings both elbows to 90 degrees of flexion.
3. Patient slowly opens and closes their hands for 3 minutes.

Positive sign: Inability to maintain the upper limb position, ischemic pain, numbness or paresthesia of the limb, or heaviness of the arm.

Question 18

What is the procedure for Allen’s Test for the shoulder?

Answer 18

1. Patient’s shoulder is abducted to 90 degrees, and the elbow is flexed to 90 degrees.
2. Therapist palpates the radial pulse as the patient contralaterally rotates their head.

Positive sign: Radial pulse weakens or disappears.

Question 19

What should be evaluated in muscle tests for Thoracic Outlet Syndrome (TOS)?

Answer 19

Any relevant muscle tests related to the patient’s presentation.

Question 20

What should be checked during neurological tests for TOS?

Answer 20

Evaluate for radiculopathy by assessing:
• Myotomes
• Dermatomes
• Reflexes

Question 21

What is the purpose of joint play examination in TOS assessments?

Answer 21

To assess mobility and integrity of the joint structures.

Question 22

What should be noted during lesion site palpation in a TOS assessment?

Answer 22

• Texture of the tissues.
• Tone of the muscles.
• Tenderness at the lesion site.

Question 23

What are the indications for neural tension testing?

Answer 23

• Presence of adhesive scar tissue around the nerves.
• Increased pressure on surrounding tissues or nerves (e.g., from increased muscle tone, swelling).

Question 24

What are the precautions for neural tension testing?

Answer 24

• The patient’s signs and symptoms will re-occur.
• Neurological symptoms should dissipate when the stretch is released.
• If not performed at an appropriate (slow) pace, nerve damage can occur.
• The patient must be aware of and able to report positive signs detected during testing maneuvers.

Question 25

What are the contraindications for neural tension testing?

Answer 25

• Acute inflammatory or unstable neurological signs.
• Spinal cord injuries.

Question 26

What does each neural tension maneuver test?

Answer 26

Each neural tension maneuver tests the full neurological pathway.

Question 27

Why is it important to test all joints before performing neural tension maneuvers?

Answer 27

Each maneuver places stress across multiple joints, so all involved joints should be tested through rule-outs and functional tests first.

Question 28

Can neural tension testing maneuvers also be used for treatment?

Answer 28

Yes, testing maneuvers can be used as treatment maneuvers.

Question 29

What is the process for neural tension testing maneuvers?

Answer 29

1. The therapist guides the patient through testing one movement at a time.
2. Note the painful movement, move out of that position, and ensure symptoms dissipate before continuing.

Question 30

What steps are involved in neural tension treatment maneuvers?

Answer 30

1. Guide the patient through one movement at a time.
2. Ask about pain/symptoms after every movement.
3. When pain/symptoms occur, move out of the position and ensure symptoms dissipate within a few seconds.
4. Return to the painful/symptomatic position and hold for 15-20 seconds.
   • Repeat until the position is no longer painful/symptomatic (max of 3 times).
5. Move on to the next position where pain/symptoms return.
6. Repeat until the final movement is complete.

Question 31

What should the therapist ask the patient while performing neural tension maneuvers?

Answer 31

“What do you feel?”
• Common responses: aching, pulling, tingling, pressure, or numbness.
• If the patient feels burning or shooting pain, the nerve is considered irritable, and all maneuvers should cease.

“Where do you feel the pain/symptoms?”
• This helps identify where along the nerve pathway it is being compressed.

Question 32

What should the therapist do if the patient’s nerve becomes irritable during neural tension testing?

Answer 32

Apply:

• Cool hydrotherapy.
• Light massage.
• Fluid techniques.

Question 33

What can the location of the neural stretch pain indicate?

Answer 33

The location where the patient feels the neural stretch can indicate where along the nerve pathway it is being compressed.

Question 34

Describe the steps for ULNT1 (Median Nerve) maneuver.

Answer 34

• Patient is supine.
• Apply shoulder girdle depression and slight abduction of the shoulder.
• Apply elbow extension alongside slight external rotation of the shoulder.
• Apply supination of the forearm.
• Apply wrist, finger, and thumb extension.
• Apply greater abduction.

Question 35

What does ULNT2 test, and what are the steps?

Answer 35

• Tests the Median Nerve, Musculocutaneous Nerve, and Axillary Nerve.
• Patient is supine.
• Apply shoulder girdle depression and slight abduction of the shoulder.
• Apply elbow extension alongside full external rotation of the shoulder.
• Apply supination of the forearm.
• Apply wrist, finger, and thumb extension.
• Apply greater abduction.

Question 36

What are the steps for ULNT3 (Radial Nerve)?

Answer 36

• Patient is supine.
• Apply shoulder girdle depression and slight abduction of the shoulder.
• Apply elbow extension alongside internal rotation of the shoulder.
• Apply pronation of the forearm.
• Apply wrist, finger, and thumb flexion with wrist ulnar deviation.
• Get the patient to contralaterally side flex their cervical spine.

Question 37

How do you perform ULNT4 (Ulnar Nerve)?

Answer 37

• Patient is supine.
• Apply wrist extension and forearm supination.
• Apply elbow flexion.
• Apply shoulder girdle depression.
• Maintain above positions and add lateral rotation and abduction.
• Get the patient to contralaterally side flex their cervical spine.

Question 38

How do you test the Sciatic Nerve in LLNT?

Answer 38

• Patient is supine.
• Bring the lower extremity into the SLR (Straight Leg Raise) position.
• Apply ankle dorsiflexion.
• Apply hip adduction.
• Apply hip internal rotation.
• Apply cervical flexion.

Question 39

What can you add to the Sciatic Nerve maneuver to increase tension on specific nerve tracts?

Answer 39

• Tibial tract: Add eversion to dorsiflexion.
• Sural tract: Add inversion to dorsiflexion.
• Common peroneal tract: Add plantarflexion with inversion.

Question 40

How do you perform the Femoral Nerve LLNT maneuver?

Answer 40

• Patient is prone with a neutral spine.
• Apply knee flexion.
• Apply hip extension (ensuring the spine does not extend, which could cause nerve root pressure and a false positive).