Thoracic Outlet Syndrome (TOS)

Question 1

Thoracic Outlet Syndrome (TOS)

Answer 1

TOS results from compression static/dynamic, either in combination or separatelt, of the subclavian artery, subclavian vein or brachial plexus in the thoracic outlet

Types:

• Arterial Vascular TOS
• Venous Vascular TOS
• Traumatic Neurovascular TOS
• Neurological TOS
• Non-Specific TOS

Causes:

• Congenital Abnormalities
• Trauma
• Acquired/Functional
• Pathological

Question 2

TOS Symptoms

Answer 2

TOS is a diagnosis of exclusion

Vascular TOS Symptoms:

• Edema
• Cyanosis
• Phlebitis
• Effort induced ischemia
• Positional vasomotor changes
• Raynaud’s Phenomeon
• Diminished or absent pulses

Neurological TOS Symptoms:

• Lower brachial plexus involvment (c8-t1)
• vague and inconsistent symptoms
• pain at rest
• pain in neck and shoulders
• numbless in limbs
• decresed strength
• difficulty with overhead symptoms
• peripheral neuropathies
• poor fine finger movements

Abnormal Presentations:

• progressive atrophy
• pain and sensory changes may be absent in intial presentations

Question 3

Roo’s Test

Elevated Arm Stress Test

Answer 3

Most reliable for TOS but also non specific

Tests 3 sites of TOS - scalene, costoclavicular and axillary

Purpose:

• Test for compromsie of neurostructures that p[ass through brachium
• Narrows costoclavicular space and tightens cervical muscles

Procedure:

• Pt sits or stands and practitioner is close to observe symptoms
• Pt abducts and externally rotates shoulders and flexes arms to 90, elbows are slightly behind
• Pt opens and closes hands slowly for 3 minutes

Positive

• Minor fatigue and distress is not positive
• positive is if the pt cannot keep their arms up for 3 minutes and experience ischemic pain, weakness, arm heaviness or numbness and tingling

Indication of Positive

• Must rule out other causes of vascular and neuro compromise - pancoast tumor
• TOS

Notes:

• Symptoms replicated need to be the exact same

Question 4

Adson Maneuver

Answer 4

Purpose:

• Compression of neurovascular bundle in the costoclavicular space

Procedure:

• Pt is sitting and examiner is behind
• Locate the radial pulse and rotate head towards the same side
• extend and externally rotate arm
• Extend neck and hold breathe
• hold for 30 seconds

Positive:

• Symptom reproduction, with or without dissappearence of radial pulse, indicates positive test

Indication of Positive:

• Rule out all other causes of vascular and neuro compromise - cervical radiculopathy
• TOS

Notes:

• Only positive if symptoms are exact

Question 5

Costoclavicular Maneuver

Answer 5

Purpose:

• Compression of neurovascular bundle in costoclavicular space

Procedure:

• Pt is sitting and examinaer is behind
• find radial pulses and draw shoulder blades down and into extension
• pt is asked to flex neck and hold for 30 seconds

Positive:

• symptom reproduction with or without pulse dissappearence is postive test

Indication of postive:

• rule out other causes of vascular and neuro compromise - brachial neuritis
• TOS

Note:

• must reproduce symptoms exactly

Question 6

Wright Maneuver

Answer 6

Purpose:

• Test for TOS from costoclavicular syndrome or pec minor syndrome

Procedure:

• Pt is sitting and practitioner stands behind
• find radial pulse and externally rottate and hyperabduct arm
• Add steps to provocate such as hold breathe or rotate head and head extend

Positive:

• Symptom reproduction with or without radial pulse disappearence indicates postive test

Indication:

• must rule out other causes of vascular or neuro compromise
• TOS

Note:

Must replicate symptoms exactly