0008 Thoracic Outlet Syndrome

Thoracic outlet syndrome
3/23/2024 Musculoskeletal physiotherapy I 1

What is thoracic outlet??
 The thoracic outlet is the space between clavicle and
first rib.
 This narrow passageway is crowded with blood vessels,

muscles, and nerves.
 If there is pressure in this space then causes a variety of

symptoms which together are known as thoracic outlet
syndrome.

Boundaries of TOS
 Posteriorly: T1 vertebral body
 Laterally: first rib and costal cartilage
 Anteriorly: manubrium sterni

TOS……………
 TOS is a nonspecific diagnosis representing many
conditions that involve the compression of the
neurovascular structures that pass through the thoracic
outlet.
 The first rib, scalene muscles, and the clavicle

comprise the thoracic outlet.

Thoracic outlet syndrome/TOS
 A collection of neurovascular symptoms brought about
by abnormal compression /pressure of the
neurovascular bundle by bony, ligamentous or
muscular structures in the narrow space between clavicle
and 1st rib.
 The specific structures compressed are usually;
– nerves of the branchial plexus and
– subclavian artery or subclavian vein

Description of the spaces in the thoracic outlet
1.The interscalene triangle:
 The most proximal passageway and bordered by:
– Anteriorly, by anterior scalene muscle
– Posteriorly, by middle scalene muscle, and
– Inferiorly, by medial surface of the first rib
 NOTE: Brachial plexus and subclavian artery pass

through this space.
Scalene muscle triangle

Cont…. …
2. The costoclavicular triangle:
 Bordered;
– Anteriorly, by middle third of the clavicle,
– posteromedially by first rib, and
– posterolaterally by upper border of scapula
 Subclavian vein passes anterior to the anterior scalene

muscle then joined branchial plexus and subclavian
artery.
Cont.………
3. subcoracoid/sub-pectoralis minor space:
 Last passageway and located beneath the coracoid

process just under the pectoralis minor tendon
 Neurovascular bundle after passing costoclavicular

triangle and then further enters the subcoracoid space
 The borders of the thoraco-coraco-pectoral space

include the coracoid process superiorly, the pectoral
minor anteriorly, and ribs 2-4 posteriorly.
Costoclavicular and subcoracoid space

Epidemiology
 TOS affects approximately 8% of the population
 3-4 times as frequent in woman as in men between the age

of 20 and 50 years.
 The mean age of people effected with TOS is 30s-40s;
 It is rarely seen in children.
 Almost all cases of TOS (95-98%) affect the brachial

plexus; the other 2-5% affecting vascular structures, such
as the subclavian artery and vein.
Etiologies
 Congenital factors:
– Cervical rib
– Fibrous muscular bands
– Abnormalities of the insertion of the scalene muscles
– Exostosis(Overgrowth of bone) of the 1st rib
– Congenital uni/bilateral high scapula
NB: Cervical ribs, extra ribs typically arising from the
seventh cervical vertebrae, is one of the most common
offenders for thoracic outlet syndrome
Cont’d. ……
 Acquired conditions:
 Postural factors:
 Dropped shoulder condition( Trapezius

muscle deficiency, clavicle #)
 Wrong work posture (standing or sitting without

paying attention to the physiological curvature of the
spine)
 Heavy mammaries (for female)

Cont……. …
Trauma:
– Clavicle fracture
– Rib fracture
– Hyperextension neck injury, whiplash
– Repetitive stress injuries (repetitive injury most

often form sitting at a keyboard for long hours)

Cont…….. …
Muscular causes:
– Hypertrophy of the
scalene muscles
– Shortening of the
scalene muscles, M.
trapezius, M. levator
scapulae, pectorals
muscles

Signs and symptoms
 The neurogenic presentation:
– Pain in the area of the shoulder, neck, radiating to the
arm, hand,
– Paresthesias
– Hand weakness or motor loss
– Loss of the fingers movement
– Tingling in the hand
– Numbness
Cont …
 The arterial presentation: (compression of the
subclavian artery)
– Coldness, weakness, heaviness and
– Paleness of the hand
– Ischemia

Cont’d……… …
 The Venous presentation: (compression of the
subclavian vein)
– Edema/swelling of the hand and forearm
– Tensed feeling of the arm
– Cyanosis

Subjective Assessment
 Mode of onset
(spontaneous vs traumatic)
 History of pain, numbness or tingling of the upper

limb
 Cold hands, swelling or blanching

Physical Examination
 A careful neurological and musculoskeletal examination
is required
 Stress tests or provocative maneuvers
 Other diseases of the neck and arm must be ruled out.

Physical Findings
 Tenderness over scalene muscles in supraclavicular area
 Pressure in supraclavicular area elicits symptoms in

arm/hand
 Tinel's sign over brachial plexus is positive

Neurologic Examination
 Examinations focused on nerve conduction
– Sensory examination (light touch, pinprick)
– Motor examination (muscle power, reflex)

Roos stress test
 It is also known as the “elevated arm stress test”.
 Diagnostic tool used in the identification of TOS
Starting position:
 Patient on standing/sitting position

 Both arms in 90° ABD & ER position
Instruction:
 The patient to open and close the hands slowly over a 3-minute
period
Results if normal:
 Only forearm muscle fatigue and minimal ache

Cont’d….. …
 Positive sign:
– if the patient cannot complete the full 3 minutes.
Note:
– This test is difficult even for those without

neurovascular symptoms
– Its practical application is limited

Adson’s test
 Radial pulse (at the wrist) is palpated and a baseline pulse is taken
 The pulse is monitored as the subject ABD, EXT, and ER the arm.
 The subject takes a deep breath and holds it for 30 seconds while
rotating, extending and side bending the neck towards the
affected arm
A positive test:
– Reduced or obliterated radial pulse
– The subject experiencing neurological or vascular symptoms.

Other tests
Focal stress tests:
 Direct application of pressure to the anterior scalene or

upper segment of the pectoralis minor.
 Positive result is if symptoms are reproduced within 15

to 30 seconds
 Use Tinel's sign, by percussing over the plexus

reproduces symptoms

Imaging
 Chest X-ray
 May show a tumor or an extra rib.
 Electromyography and nerve conduction studies
 Eventually
– MRI
– CT
– US
– Arteriogram
Differential Diagnosis
– Carpal tunnel syndrome
– Ulnar nerve entrapment
– Cervical disease (radiculopathy)
– Brachial plexus trauma
– Rotator cuff pathology
– Glenohumeral joint instability

Differential diagnosis
 Rotator cuff/AC joint tenderness;
 Tinel's sign and/or Phalen's sign at wrist suggests

carpal tunnel syndrome
 Tinel's sign at elbow (over ulnar groove) suggests

ulnar nerve entrapment

Treatment
 Physiotherapy include:
 Ultrasound
 Electrical stimulation
 Stretching exercises
 Scalene, pectoralis minor, trapezius and levator scapulae
 Postural correction exercises
 Education in correct body mechanics:
• Sleep postures, activities of daily-living and work-station

design is important to prevent re-injury.
Surgery
 Surgery should be a last alternative
 If there is clear evidence of a lesion impinging on a
nerve or vessel by
– First rib
– scalene muscles
– Cervical ribs
– fibrous bands
 Then they should be cut
Surgical procedures used
– First rib resection
– Anterior and/or middle scalenectomy
– Combined first rib resection and scalenectomy

Any
Questions
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Thoracic outlet syndrome

3/23/2024 Musculoskeletal physiotherapy I 1

 This narrow passageway is crowded with blood vessels,

 If there is pressure in this space then causes a variety of

3/23/2024 Musculoskeletal physiotherapy I 3

 Laterally: first rib and costal cartilage

 Anteriorly: manubrium sterni

3/23/2024 Musculoskeletal physiotherapy I 4

 The first rib, scalene muscles, and the clavicle

3/23/2024 Musculoskeletal physiotherapy I 7

 The specific structures compressed are usually;

– nerves of the branchial plexus and

– subclavian artery or subclavian vein

1.The interscalene triangle:

 The most proximal passageway and bordered by:

– Anteriorly, by anterior scalene muscle

– Posteriorly, by middle scalene muscle, and

– Inferiorly, by medial surface of the first rib

 NOTE: Brachial plexus and subclavian artery pass

3/23/2024 Musculoskeletal physiotherapy I 10

– Anteriorly, by middle third of the clavicle,

– posteromedially by first rib, and

– posterolaterally by upper border of scapula

 Subclavian vein passes anterior to the anterior scalene

 Last passageway and located beneath the coracoid

 Neurovascular bundle after passing costoclavicular

 The borders of the thoraco-coraco-pectoral space

3/23/2024 Musculoskeletal physiotherapy I 13

 3-4 times as frequent in woman as in men between the age

 The mean age of people effected with TOS is 30s-40s;

 It is rarely seen in children.

 Almost all cases of TOS (95-98%) affect the brachial

 Dropped shoulder condition( Trapezius

 Wrong work posture (standing or sitting without

 Heavy mammaries (for female)

– Hyperextension neck injury, whiplash

– Repetitive stress injuries (repetitive injury most

3/23/2024 Musculoskeletal physiotherapy I 17

3/23/2024 Musculoskeletal physiotherapy I 18

– Hand weakness or motor loss

– Loss of the fingers movement

– Tingling in the hand

– Coldness, weakness, heaviness and

– Paleness of the hand

3/23/2024 Musculoskeletal physiotherapy I 21

– Edema/swelling of the hand and forearm

– Tensed feeling of the arm

3/23/2024 Musculoskeletal physiotherapy I 22

 History of pain, numbness or tingling of the upper

 Cold hands, swelling or blanching

3/23/2024 Musculoskeletal physiotherapy I 23

 Stress tests or provocative maneuvers

 Other diseases of the neck and arm must be ruled out.

3/23/2024 Musculoskeletal physiotherapy I 24

 Pressure in supraclavicular area elicits symptoms in

 Tinel's sign over brachial plexus is positive

3/23/2024 Musculoskeletal physiotherapy I 25

– Sensory examination (light touch, pinprick)

– Motor examination (muscle power, reflex)

3/23/2024 Musculoskeletal physiotherapy I 26