Thoracic Outlet Syndrome (TOS) Flashcards
What is the pathoanatomy of TOS?
Neurovascular Entrapment
5 sites of compression
- Subclavian artery and lower roots between the anterior and middle scalene
- Subclavian artery and vein and lower trunk in the costoclavicular space
- Axillary artery and vein and cords in subcoracoid tunnel
- When the GH is laxed (may cause compression)
- Cervical rib (When the transverse process of C7 continues to grow and acts as rib), this may cause compression
With TOS, what are the different classifications? (4)
- Vascular thoracic outlet; arterial TOS (aTOS)
–Compression of the subclavian-axillary artery - Vascular thoracic outlet; venous TOS (vTOS)
–Compression of the subclavian-axillary vein - Neurologic thoracic outlet; True neurologic TOS (tnTOS)
–Traction or compression injury to the brachial plexus - Neurogenic thoracic outlet; Symptomatic TOS (sTOS)
–Repetitive compression and tensioning causing neural irritation of the brachial plexus
With TOS, what is Double Crush Syndrome?
Nerve Entrapment that occurs at multiple sites
- Cervical, thoracic outlet, elbow, forearm, and wrist
What other conditions should be considered with patients with TOS?
- Neck P! with Mobility Deficit
- Neck P! with Movement Coordination Deficit
- Neck P! with Radiating Pain
- Thoracic Mobility Deficit
- Rotator cuff related shoulder pain
- Medial Epicondalgia
- Ulnar Nerve Palsy
What system, structure, pain mechanism, and phases of healing are unique to patients with TOS?
System
- Neuromusculoskeletal, Vascular
Structure
- Brachial Plexus, Subclavian-axillary artery and vein
Pain Mechanism
- Neuropathic, Nociceptive
Phase of Healing
- Nerve 2-3 mm/day (1 inch a month)
With TOS, what are common subjective reports with Arterial TOS (aTOS)?
- UE fatigue/paresthesia with the use of the arm
- Cold sensitivity or Raynaud’s
With TOS, what are common subjective reports with Venous TOS (vTOS)?
- UE pain, venous engorgement and edema
- Cyanosis and fatiguability
- Feeling of stiffness
With TOS, what are common subjective reports with True Neurologic TOS (tnTOS)?
- Pain and paresthesia in the neck, chest and UE
- Weakness and numbness in the distribution of the involved neural structure
With TOS, what are common subjective reports with Symptomatic TOS (sTOS)?
- Pain and paresthesia commonly in the ulnar distribution
- Provoked with the repetitive use of the UE and positioning above the shoulder height
With TOS, what is a common 24 hour Pain Behavior?
Morning
- May have pain, paresthesia, stiffness that upon waking
Noon to evening
- Symptoms may vary throughout the day depending on the patients activities, may have increased symptoms with overhead activities
Night
- Symptoms may disrupt sleep with changing positions depending on symptom irritability and sleeping position
With TOS, what should take part in the Systems Review?
This is indicated from the subjective examination
- Cardiopulmonary
–Vitals
–Visual inspection and palpation - Neuromusculoskeletal
–Reflexes/pathological reflexes
–Dermatomes/Myotomes
With TOS, when conducting the Movement and Provocation Examinations, what 3 examinations must you do?
Cervical Clearing Examination
Active ROM
Passive Intervertebral Motion
Spurling A and Distraction
Shoulder Examination
Active and Passive ROM (Looking for movement quality and assessing symptom reproduction, Flexion and Abduction may reproduce symptoms)
Neurological Testing
ULND Test 1 / ULTTA
ULND Test 2 / ULTTB
ULND Test 3 / ULTTC
With TOS, when conducting the Movement and Provocation Examination, what may you find with Thoracic Spine and Ribs Active ROM?
- Inhalation/Exhalation (Breathing assessment, there may be symptom during inhalation because elevation of the first rib and contraction of the scalenes)
- Thoracic and rib ROM limitations
With TOS, when conducting the Movement and Provocation Examination, what may you find with Thoracic Spine and Ribs Passive Intervertebral Motion (PIVM)?
- Hypomobility throughout the thoracic spine and ribs
- Hypomobility and symptom relief with first rib depression
With TOS, when conducting the Muscle Performance Examination, which muscles will you test for Muscle coordination, endurance, strength, and length?
- Deep neck flexors/extensors, middle/lower trapezius, rhomboids, serratus anterior
- Upper Trapezius, levator scapulae, scalenes, suboccipitals, SCM, Pec minor/major and diaphragm
