Thoracic Outlet Syndrome Flashcards
1
Q
What is TOS?
A
Thoracic Outlet construct
- Clavicle
- 1st rib
- Anterior/Middle Scalene
- Pectoralis Minor/Coracoid
Neurovascular Bundle
- Brachial Plexus
- Motor and sensory nerves that innervate the UE
- C8-T1 nerve roots
- Subclavian artery and vein
2
Q
What are the types of compression?
A
Types on Compression’
- Arterial
- 1% of all cases
- Venous
- 2% of all cases
- Neurologic
- 97%
- Young/middle age adults
- Women outnumber men (2:1)
- Compression Sites
- Scalene Triangle
- Anterior/medial scalene (medial)
- 1st Rib (inferior)Floor
- Subclavian Artery and brachial plexus only
- Subclavian vein anterior to this space
- Costoclavicular Region
- Clavicle (superior)
- 1st Rib (inferior)
- Axillary Region
- Pectoralis Minor/ Coracoid Process
- 97%
3
Q
What are the borders for TOS?
A
Borders
- Anterior: Anterior Scalene
- Posterior: Medial Scalene
- Superior: Clavicle
- Inferior: 1St rib
- Lateral : Pectoralis Minor and Coracoid
4
Q
What are the symptoms?
A
Symptoms
- Pain/Swelling
- Numbness
- Tingling in hand and forearm
- Pain and tingling in the neck/shoulders
- Signs of poor circulation the hand/forearm
- Bluish discoloration of the hand
- Weaknesses of the muscles of the hand
- Feeling of heaviness of the arm
- Deep toothache-like pain in the neck/shoulder-worsens at night
- Hand/arm easily fatigues
5
Q
What are the causes of TOS?
A
Causes
- Compressive Neuropathy
- Postural Abnormalities
- Entrapment Neuropathy
Causes:Compressive Neuropathy
- Anterior Scalene tightness
- Compression of the interscalene space between the anterior and middle scalene
- Nerve root irritation, spondylosis or facet joint inflammation leading to muscle spasm.
- Costoclavicular Approximation
- Compression in the space between the clavicle, the first rib and the muscular and ligamentous structures in the area
- postural deficiencies or carrying heavy objects.
- Pectoralis Minor Tightness
- Compression between pectoralis minor tendon /corocoid process and the clavicle
- Above head repetitive motions (should elevation/abduction)
6
Q
What are the other causes of TOS?
A
Causes: Postural Abnormalities
- Forward Head
- Cervical extensor weakness
- Rounded Shoulder
- Pectoralis tightness
- Rhomboid weakness
- Guarding Position
- Shoulder evelation, cervical muscle tightness
Causes: Entrapment Neuropathy
- Decreased ability of the nerve(s) to glide through surrounding tissue
- Increases tension on nerve
- Secondary to:
- Neural fibrosis associated with cervical or shoulder trauma
- Repetitive stress activities
- Scarring post radiation
7
Q
What is the diagnosis?
A
Differential Diagnosis
- Trigger Points
- Neurofibromas – nerve tumor/growth
- Cervical disk abnormalities
- Median Nerve Compression
- Tinel’s, Phalen’s
- Ulnar Nerve Compression
- Tinel’s, Elbow flexion test
- Complex Regional Pain Syndrome/RSD
- Rotator Cuff Injury
- Osteoarthritis
8
Q
What is the evaluation for TOS?
A
Evaluation:
- History
- Mechanism/site of injury
- Onset and duration
- Detailed description of symptoms (pain vs. parathesia)
- Positions/activities that exacerbate symptoms
- Medical history and test results
- Physical Exam
- Posture, pain, skin temp, edema
- Grip Strength/pinch
- ROM
- MMT
- Supraclavicular Tinel’s
- Provocative Tests
- Vascular compression: Adson’s, Costoclavicular maneuver, Hyperabduction
- Brachial Plexus: East/Roo’s, Elvey’s, Hunter, Erb,
-
Physical observation: Hand/Upper Quadrant/Cervical region
- Prior injuries, surgeries, skin condition
- Changes in color, nail growth, protective posture: RSD
- Severe drooping of shoulder with clavicle below horizontal – compression between first rib and clavicle
- Neck lateral or forward: chronic scalene shortening
- Attempt to decrease tension on the brachial plexus by elevating the scapula and rotating and laterally flexing to affected side
- Sitting / standing posture
- Forward head/rounded shoulder
- Accessory breathing patterns
- Position of UE
- Is patient attempting to decreases neural tension distally by maintaining elbow in flexion, forearm neutral and wrist/digits in flexion?
9
Q
What are the provacative tests?
A
Provocative Tests
- One piece of the puzzle: The presence or absence of provocative neither confirms or eliminates TOS
- The presence of parathesias in many of the tests in of more clinical importance than the loss of pulse
- The exception: Adson’s manuever or by elevation of the arm less than 70 degrees
- Symptoms elicited from these test indicate either traction or compression placed on the nerves of the plexus with arm or neck movement
- Vascular compression: Adson’s, Halsted’s test, Wright’s, Costoclavicular maneuver, Hyperabduction
- Brachial Plexus: East/Roo’s, Elvey/Hunter, Erb,
10
Q
What is another upper limb test?
A
Upper Limb Tension con’t
- Pt positioned in supine
- Examiner takes clients arm into abduction and external rotation behind the coronal plane at the shoulder (shoulder girdle in depression)
- Elbow is extended with wrist in extension and forearm supinated
- Stretch or ache or tingling in thumb and/or digits 2 and 3 = median n involvement
- Lateral flexion of neck away from UE increases tension
- Compare to uninvolved side
11
Q
What is the test for brachial plexus involvment?
A
Provocative Test:
Brachial Plexus
- East test/Roos test (‘Hands Up”)
- The patient brings their arms up in “field goal position” (bilateral shoulders/elbow @ 90 with lateral rotation) and elbows slightly behind the head.
- The patient then slowly opens and closes their hands slowly for 3 minutes
- A positive test is indicated by pain, heaviness or profound arm weakness or numbness and tingling of the hand or inability to hold positition for 3 minutes
12
Q
What is the test for vascular compression, Adson or Scalene Maneuver?
A
Provocative Test:
Vascular Compression
Adson or Scalene Maneuver
- The examiner locates the radial pulse.
- The patient rotates their head toward the tested arm and lets the head tilt backwards (extends the neck) and takes a deep breath while the examiner extends and laterally rotates the shoulder.
- A positive test is indicated by a disappearance or slowing of the pulse.
13
Q
What is the Costoclavicualr maneuver?
A
Provocative Test:
Vascular Compression
Costoclavicular Maneuver
- The examiner locates the radial pulse and draws the patient’s shoulder down and back as the patient lifts their chest in an exaggerated “at attention” posture.
- A positive test is indicated by an absence of a pulse or reproduction of symptoms.
- This test is particularly effective in patients who complain of symptoms while wearing a back-pack or a heavy jacket.
14
Q
What is the hyperabduction test?
A
Provocative Test:
Vascular Compression
Hyperabduction Test
- Arm held by clinician in fully abducted position to test for compression at pectoralis minor insertion
- Note reproduction of symptoms or decreased radial pulse
15
Q
What is the passive elevation test?
A
Provocative Test
Passive Elevation Test
- This test is used on patients who already present with symptoms.
- The patient sits with arms crossed over chest.
- The examiner grasps the patient’s arms from behind at the elbows (hug)
- The patient is passive as the shoulders are elevated
- The position is held for 30 seconds or more. This activity is evidenced by increased pulse, skin color change (more pink) and increased hand temperature.
- Neurological signs go from numbness to pins and needles or tingling as well as some pain as blood flow to the nerve returns. Similar to what is felt after an arm “falls asleep” and circulation returns.
