Thoracic Outlet Syndrome

Question 1

What is thoracic outlet syndrome?

Answer 1

Entrapment of nerves and vasculature

Question 2

What is thoracic outlet syndrome a result of?

Answer 2

Compression of the neurovascular bundle as it courses through the neck and shoulder
Brachial plexus, subclavian artery, subclavian vein

Question 3

What structure do the nerves, veins, and arteries pierce?

Answer 3

Sibson’s fascia

Question 4

When the fascia becomes taught what can occur?

Answer 4

Ensnare nerves and arteries

Question 5

What are the presenting complaints of thoracic outlet syndrome?

Answer 5

Pain and numbness o the upper extremity typically extending along ulnar aspect of hand
Pain worse with arm elevated or abducted
Weakness of hand - maybe atrophy

Question 6

In thoracic outlet syndrome what may develop?

Answer 6

Shoulder and arm pain, weakness, paresthesia, claudication, raynaud phenomenon, ischemic tissue loss, gangrene (rare)

Question 7

What are the physical findings for thoracic outlet?

Answer 7

Sensory loss in the ulnar distribution, weakness on intrinsic ulnar muscles, local tenderness

Question 8

What are some other physical findings in thoracic outlet?

Answer 8

Dec’absent distal pulse, digital cyanosis and ischemia, tenderness of supraclavicular fossa, maybe autonomic dysfunction
Possible bruit of subclavian artery

Question 9

What is the pathophysiology of thoracic outlet?

Answer 9

Compression of neurovascular bundle as it courses out of thoracic outlet

Question 10

Where can compression occur in TOS?

Answer 10

Anterior and middle scalenes
Clavicle and 1st rib
Pectoralis minor and upper ribs
Cervical rib

Question 11

What is the “double-crush” phenomenon?

Answer 11

Compression of the median nerve under the transverse carpal ligament, between the two heads of the pronator teres, or at the brachial plexus in the thoracic outlet

Question 12

Describe Adson’s test.

Answer 12

Monitor pt’s pulse by extending, abducted, and externally rotating the shoulder,

Question 13

If there is a positive Adson’s test what does that mean?

Answer 13

Significantly dec/absent

Compression between middle and anterior scalenes

Question 14

Describe Wright’s test.

Answer 14

Arm hyperextension test

Hyperabduct arm above head

Question 15

What does a positive Wright’s test mean?

Answer 15

Pulse significantly dec/absent

Compression between pectoralis minor and upper ribs

Question 16

Describe the costoclavicular syndrome test.

Answer 16

Military posture test

Depress, extend shoulder while flexing head bringing chin to chest, and back and neck posteriorly

Question 17

What does a positive costoclavicular syndrome test mean?

Answer 17

Pulse significantly dec/absent

Compression between clavicle and 1st rib

Question 18

Describe Roos Test.

Answer 18

Pt stand with both arms abducted to 90 degrees, elbow flexed at 90 and slightly posterior to frontal plane
Open and close the hands slowly over 3-minute period

Question 19

What does a negative Roos test mean?

Answer 19

If forarm muscle fatigue after minimal distress

Question 20

What does a positive Roos test mean?

Answer 20

If pt is unable to keep arms is this position for 3 min, experiences heaviness, profound weakness, or reproduction of their symptoms

Question 21

What does it mean if the pt’s finger cyanose in a Roos test?

Answer 21

Consider subclavian venous problem

Question 22

What is the normal range of false positives for these test?

Answer 22

Adson’s test = 9%

Costoclavicular = 16%

Question 23

What is the standard management for TOC?

Answer 23

Conservative management
Avoid positions that aggravate symptoms 
OMT
Exercise 
Medications (Analgesics, NSAIDs, muscle relax)
Physical therapy
Surgical intervention

Question 24

What are the goals of OMT management for TOC?

Answer 24

Improve mechanics for cervical, thoracic, upper ribs, clavicles, scalenes, and shoulder/pec girdle muscles

Question 25

What are some OMT to use?

Answer 25

Myofascial release techniques

Eval of work and life style