{"id":14496,"date":"2023-02-10T15:59:44","date_gmt":"2023-02-10T14:59:44","guid":{"rendered":"https:\/\/www.physiotutors.com\/?post_type=condition&p=14496"},"modified":"2024-05-20T19:56:26","modified_gmt":"2024-05-20T17:56:26","slug":"thoracic-outlet-syndrome","status":"publish","type":"condition","link":"https:\/\/www.physiotutors.com\/conditions\/thoracic-outlet-syndrome\/","title":{"rendered":"Thoracic Outlet Syndrome"},"featured_media":14497,"template":"","class_list":["post-14496","condition","type-condition","status-publish","has-post-thumbnail","hentry"],"acf":{"sections":[{"acf_fc_layout":"page-header-detail-page","background":{"background_image":14497,"background_image_alt_text":"Thoracic Outlet Syndrome"},"heading":"Thoracic Outlet Syndrome | Diagnosis & Treatment for Physios","subheading":"Thoracic","content_editor":"","button_type":"url","button_label":"","button_style":"button-five","button_internal_link":4646,"button_anchor":"","button_url":"https:\/\/study.physiotutors.com\/course\/orthopedic-physiotherapy-of-the-spine\/","button_file":"","label":""},{"acf_fc_layout":"submenu","links":[{"button_type":"anchor","button_label":"Introduction & Epidemiology","button_internal_link":null,"button_anchor":"section-number-3","button_url":"","button_file":null},{"button_type":"anchor","button_label":"Clinical Picture & Examination","button_internal_link":null,"button_anchor":"section-number-4","button_url":"","button_file":null},{"button_type":"anchor","button_label":"Treatment","button_internal_link":null,"button_anchor":"section-number-5","button_url":"","button_file":null},{"button_type":"anchor","button_label":"Spine Online Course","button_internal_link":null,"button_anchor":"section-number-6","button_url":"","button_file":null},{"button_type":"anchor","button_label":"Course Reviews","button_internal_link":null,"button_anchor":"section-number-7","button_url":"","button_file":null}],"dropdown_label":"Go to","button_right":{"button_type":"internal_link","button_label":"Become a member","button_style":"button-three","button_internal_link":22104,"button_anchor":"","button_url":"","button_file":""},"button_description":""},{"acf_fc_layout":"content-with-sidebar","content_editor":"

Thoracic Outlet Syndrome | Diagnosis & Treatment for Physios<\/h2>\r\nThe term \"Thoracic outlet syndrome\" (TOS) was originally coined by Peet in 1956 and has emerged as one of the most controversial topics in musculoskeletal medicine and rehabilitation (Hooper et al. (2010)<\/a>. Thoracic outlet syndrome is defined as the compression of nerves or blood vessels near the base of the neck. Specifically, the compression of the brachial neural plexus, subclavian artery, subclavian vein, or any combination of these vessels may occur (Levine et al. 2018<\/a>). The pain and discomfort of TOS are generally attributed to the compression of the subclavian vein, subclavian artery, and the lower trunk of the brachial plexus as they pass through the thoracic outlet (Watson et al. 2009<\/a>).\r\nThe following video will give you an overview of the different forms of TOS as well as the pathophysiology behind it:\r\n
\r\n\r\n[embed]https:\/\/www.youtube.com\/watch?v=H_tGstO-0N4[\/embed]\r\n\r\n<\/div>\r\nWhile the distinction between tnTOS and sTOS was common in the past, Illig et al. (2016)<\/a> of the Society for Vascular Surgery published reporting standards for TOS and mention that the terms \"true, disputed, or nonspecific nTOS\" should be avoided as the difference between \"true\" and \"disputed\/nonspecific\" TOS is only based on objective symptoms observed in nerve conduction abnormalities or hand muscle atrophy. Furthermore, the term vascular TOS should be avoided as well as this term offers insufficient detail by which to characterize patients with either venous TOS (vTOS) or arterial TOS (aTOS).\r\n\r\nEpidemiology<\/strong><\/em>\r\n\r\nThoracic Outlet Syndrome is typically diagnosed in early adulthood (ages 20-40) and is more prevalent in those with the shoulder flexed for the majority of the work day, have repeated trauma to the shoulder joint, and those who exhibit abnormal posture, including positions required to play bow instruments (Levine et al. 2018<\/a>).\r\nThe most commonly presented cause of TOS is thought to be whiplash motion which can result in instability at the atlantoaxial joint, causing the surrounding musculature (like the sternocleidomastoid and scalenes) to shorten, in order to compensate for the laxity in the joint.\r\n\r\nThe incidence of TOS is reported to be approximately 8% of the population and the female-to-male ratio is estimated between 2:1 to 4:1, while Urschel et al. (2008)<\/a> report that vascular TOS is more equal between non-athletic men and women, but found to be even greater in competitive athletic men vs women (Melby et al. 2008<\/a>). 98% of all patients with TOS fall into the neurogenic TOS (nTOS) category and only 2% have vascular TOS. While neurological symptoms appear more prominently, the majority of these cannot be evaluated objectively by nerve conduction abnormalities or atrophy and would thus fall within the formerly called \"symptomatic or disputed\" TOS classification (Davidovic et al. 2003<\/a>)."},{"acf_fc_layout":"content-with-sidebar","content_editor":"

Clinical Picture & Examination<\/strong><\/h3>\r\nIt is essential that the clinician carefully considers and at least attempts to clinically differentiate, where possible, exactly which component of the neurovascular complex is being affected and precisely where it is being compressed. This will dictate not only which further investigations are required, but may well impact on what is the most appropriate treatment strategy. In reality, this is often easier said than done (Watson et al. 2009<\/a>). Unfortunately, there is no test or investigation that is able to consistently prove the diagnosis of TOS.\r\n\r\nThe following table is a modern adaption of Hooper et al. (2010)<\/a> and presents an overview of the presentation of venous, arterial, and neurological TOS:\r\n\r\n\"\"\r\n\r\nDue to the confusion around a clear definition of nTOS, Illig et al. (2016)<\/a> of the Society for Vascular Surgery published reporting standards for TOS with the primary aim to provide a clear and consistent understanding and definition of what constitutes a diagnosis of nTOS. Watch the video below, to learn more about the consensus criteria:\r\n
\r\n\r\n[embed]https:\/\/www.youtube.com\/watch?v=iHP0F3flLzY[\/embed]\r\n\r\n<\/div>\r\n \r\n\r\nExamination<\/strong><\/em>\r\nIn the following, we will explain how to use physical examination to confirm or reject the 3 criteria that you may have found during patient-history taking following the suggestions from Illig et al. (2016)<\/a>. The fourth criterion - a test injection - is outside of the scope and not feasible for a physiotherapist. The diagnosis of nTOS is confirmed if all 3 remaining items are positive:\r\n\r\n1) Local findings can be confirmed by tenderness upon palpation of the scalene triangle and pectoralis minor insertion.<\/strong><\/em>\r\n\r\n\"\"\r\n\r\n\"\"\r\n\r\n \r\n\r\n2) Positive Peripheral Findings<\/em><\/strong>\r\n\r\nUpper limb tension testing is sensitive for irritation of the neural tissue including cervical roots, brachial plexus, and peripheral nerves as well as for patients with arm pain syndrome. It has been advocated for the diagnosis of neurogenic TOS with reported high sensitivity. The test appears to be excellent for screening for sensitization of the neural tissue in the cervical spine, brachial plexus and upper limb but is not specific for one area. The test is recommended as part of the examination and for its usefulness in treatment that includes neural mobilization (Hooper et al. 2010<\/a>).\r\n
\r\n\r\n[embed]https:\/\/www.youtube.com\/watch?v=rir6x6Iiqc4[\/embed]\r\n\r\nThere are several provocation tests for TOS that are designed to stress one of the 3 possible intervals for entrapment. These are:\r\n