Thoracic Outlet Syndrome Flashcards
What is thoracic outlet syndrome?
Signs and symptoms attributable to compression (secondary to a decrease in the thoracic outlet space or shortened muscles) or traction of the neurovascular bundle at the brachial plexus
What are 4 areas within the anatomical location of the brachial plexus that are vulnerable to injury?
- Sternocostovertebral Space
- Scalene Triangle
- Costoclavicular Space
- Subcorocoid Space
What 3 structures make up the Sternocostovertebral Space?
- Sternum anteriorly
- Spine posteriorly
- First rib (laterally)
What 3 structures make up the scalene triangle?
- Anterior scalene muscle
- Middle scalene muscle
- First rib
What 2 structures travel through the scalene triangle? What structure (1) passes over the scalene triangle?
- Brachial plexus and subclavian artery travel through this triangle
- Subclavian vein passes over the first rib anterior to the anterior scalene muscle
What 2 structures form the costoclavicular space?
- Clavicle
2. First rib
What 3 structures make up the subcorocoid space?
- Corocoid process
- Insertion of the pectoralis minor
- Ribs (posteriorly)
True or False: Thoracic Outlet Syndrome is more common in men than women.
FALSE
More common in women
Ration: 3-4:1
What are 12 possible anatomical causes of thoracic outlet syndrome?
- cervical rib
- bifid first rib
- Fractured first rib
- Fusion of the first and second ribs
- Long transverse process at the cervical spine,
- Clavicular fracture/ anomaly,
- Fibrous or ligamentous bands
- pre-fixed plexus (the brachial plexus exits the spinal canal from the C4 through C8 foramina, rather than from C5 through T1)
- post-fixed plexus (the brachial plexus exits the spinal canal from the C6 through T2 foramina, rather than from C5 through T1)
- Drooping shoulder (this is common in large breasted women)
- Upper thoracic kyphosis
- Winged scapula
What posture can lead to thoracic outlet syndrome?
Forward Head Posture
What 4 positions occur as a result of forward head posture?
- Thoracic flexion
- Increased cervical lordosis (perhaps lower cervical flexion)
- Scapular abduction
- Shoulder internal rotation
What muscles (7) become tight and what muscles (2)become elongated as a result of forward head posture?
- Tightness of the scalenes, sternocleidomastoid, suboccipitals, upper trapezius, pectorals, serratus anterior, and levator scapulae
- Elongation of the middle trapezius and lower trapezius
Muscles, in either a shortened or elongated position, are placed at a mechanical ____, resulting in ____ of other muscles and perpetuating muscle imbalance
- disadvantage
2. compensatory overuse
Typically, in these scapular-abducted positions, the ___ stabilizers become weakened, causing ___ of the scapular elevators (upper trapezius, levator scapulae, upper rhomboids).”
- lower scapular
2. overuse
List 3 muscles that may have strength impairments as a result of forward head/shoulder posture.
- Middle trapezius
- Lower trapezius
- Lower cervical paraspinal and/or anterior upper cervical musculature (longus colli and longus capitus)
List 9 muscles that may have length impairments as a result of forward head/shoulder posture.
- Suboccipitals
- Scalenes
- Sternocleidomastiods
- Upper trapezius
- Levator scapulae
- Pectoralis major
- Pectoralis minor
- Serratus anterior
- Upper cervical paraspinal and / or anterior lower cervical musculature (longus colli)
Tightness or spasm in what 2 muscles can directly cause thoracic outlet syndrome?
- Scaleneus anticus/medius
2. Pectoralis minor
What can cause an elevated first rib, which causes thoracic outlet syndrome?
Apical breathing pattern, as with patients with COPD
Thoracic outlet syndrome can also be caused by a ____ injury to the brachial plexus
Traction
What position can cause a thoracic outlet injury at the costoclavicular area? What population is this commonly seen in? Intervention?
- Positioning the shoulder complex into retraction and depression
- backpack users
- Intervention consists of postural education to elevate the shoulder in a retracted position
What are 4 red flag pathologies that can mimic thoracic outlet syndrome?
- Apical lung tumor
- Aneurysm
- Embolism
- Angina
List 5 signs and symptoms of thoracic outlet syndrome.
- Parasthesia
- Weakness
- Circulatory changes in the upper extremity.
- Because most often the C8 and T1 nerve roots are affected, the neurological signs are usually located in the ulnar nerve distribution, and consist primarily of numbness in the fourth and fifth digits.
- supraclavicular shoulder pain with radiation into the medial upper arm and forearm into the fourth and fifth digits
List 2 musculoskeletal causes of pt’s signs and sxs when thoracic outlet syndrome is suspected.
- cervical spine radiculopathy
- Peripheral nerve lesion in the ulnar nerve or at the
carpal tunnel should be ruled out
This phenomenon of more than one lesion occurring along the course of one nerve is called _______.
Double Crush
Aside from usual items, what 3 conditions should the PT ask about regarding the patient’s medical history?
Whether the patient had:
- Fracture in the upper quarter
- Change in activity associated with the onset of or a change in symptoms
- Known developmental abnormalities or degenerative changes
What 2 things should the PT observe during the examination?
- Posture
2. Breathing Pattern
What muscles should be assessed with palpation?
Examine any of the muscles that are likely to cause TOS for spasm
What should be examined during the neurological examination of a patient with suspected TOS?
Examine the strength in key muscles, as well as sensation and DTRs, to rule in/out a lesion in the cervical spine or a peripheral neuropathy in a location other than the TOS.
Tests designed to examine ________ in the area of the thoracic outlet are also often recommended as a component of examining for TOS
Neural tension
List 6 special tests used to test for thoracic outlet syndrome.
- AER
- EAST = Roos Test
- Cervical Rotation Lateral Flexion Test
- Adson’s Test
- Halsted Test = Costoclavicular Test
- Wright’s Maneuver = Hyperabduction Maneuver
True or False: It is usually impossible to locate the exact site of the lesion within the thoracic outlet or the exact cause of the symptoms
TRUE
_______ interventions should be used to treat TOS.
Impairment based
List 7 possible interventions for TOS.
- Correction of the muscle imbalance and instruction in appropriate posture
- Instruction in appropriate breathing pattern
- Soft tissue mobilization, including treatment of trigger points if present
- Patient education regarding activity level and, appropriate posture, breathing and body mechanics.
- Instruction in a home exercise program
- Inferior Glide Mobilization / Manipulation of the first rib
- Neural mobilization
What is the most effective surgical operation for relief of severe thoracic outlet syndrome?
Surgical decompression of the neurovascular bundle by resecting the first rib and/or the anomalous muscle and fibrous band
