Rebranding Header Thorocic

Thoracic Outlet Syndrom
in Dubai

Definition

The thoracic outlet is a passageway through which the neuro-vascular bundle passes from the chest to the arm, Through this passageway, three pathways can happen.

The most proximal is called the interscalenous triangle; it’s borders are the first rib inferiorly, anterior scalenous anteriorly, middle scalenous muscle posteriorly, and pass through it the subclavian artery and brachial plexus.

The second passageway is called the costoclavicular triangle, which is bordered anteriorly by the middle third of the clavicle, posteromedially by the first rib, and posterolaterally by the upper border of the scapula.

The last passageway is called the subcoracoid or sub-pectoralis minor space: The borders of the thoracic-coraco-pectoral space include the coracoid process superiorly, the pec minor anteriorly, and ribs 2-4 posteriorly

TOS affects approximately 8% of the population and is 3–4 times as frequent in women as in men between the ages of 20 and 50. The mean age of people affected by TOS is 30–40; it is rarely seen in children. Almost all cases of TOS (95–98%) affect the brachial plexus; the other 2–5% affect the subclavian artery and vein.

Causes

Congenital Factors:

  • Cervical rib
  • Prolonged transverse process
  • Anomalous muscles
  • Fibrous anomalies (transversocostal, costocostal)
  • Abnormalities of the insertion of the scalene muscles
  • Fibrous muscular bands
  • Exostosis of the first rib
  • Cervicodorsal scoliosis
  • Congenital unilateral or bilateral elevated scapula

Location of the A. or V. Subclavian in relation to the M. scalene anterior

Acquired Conditions:

  • Postural factors
  • Dropped shoulder condition
  • Wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine)
  • Heavy mammaries
  • Trauma
  • Clavicle fracture
  • Rib fracture
  • Hyperextension neck injury, whiplash
  • Repetitive stress injuries (repetitive injury, most often from sitting at a keyboard for long hours)

Muscular Causes:

Hypertrophy of the scalene muscles
Decrease of the tonus of the M. trapezius, M. levator scapulae, M. rhomboids
Shortening of the scalene muscles, M. trapezius, M. levator scapulae, and pectoral muscles

Clinical Presentation

Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of the nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb-threatening complications in severe cases.

Signs and symptoms are typically worse when the arm is abducted overhead and externally rotated with the head rotated to the same or opposite side. As a result, activities such as overhead throwing, serving a tennis ball, painting a ceiling, driving, or typing may exacerbate symptoms.

Compressors* - a patient that experiences symptoms throughout the day while using prolonged postures resulting in increased tension or compression of the thoracic outlet. The most common aggravating postures are head forward with the shoulder girdles protracted and depressed, or activities that involve working overhead with the arms elevated. These positions cause an increase in tension/compression (such as working overhead with elevated arms) that would increase tension or compression of the neurovascular bundle of the brachial plexus

Releasers* - Describes patients who often experience paraesthesia at night that often wakes them up. It is caused by a release of tension or compression to the thoracic outlet, that restores the perineural blood supply to the brachial plexus, signaling a return to normal sensation. This is used as an indicator of a favorable outcome and resolution of symptoms.

Physical Examination
Observation

  • Posture
  • Cyanosis
  • Oedema
  • Paleness
  • Atrophy

Palpation

  • Temperature changes
  • Supraclavicular fossa
  • Scalene muscles (tenderness)
  • Trapezius muscle (tenderness)

Neurological Screen

MMT & flexibility of the following muscles:

  • Scalene
  • Pectoralis major/minor
  • Levator scapulae
  • Sternocleidomastoid

Serratus anterior

Special Tests

Elevated Arm Stress/ Roos test: The patient has arms at 90° abduction, and the therapist puts downward pressure on the scapula as the patient opens and closes the fingers. If the TOS symptoms are reproduced within 90 seconds, the test is positive.

Adson's: The patient is asked to rotate the head and elevate the chin toward the affected side. If the radial pulse on the side is absent or decreased, then the test is positive, showing the vascular component of the neurovascular bundle is compressed by the scalene muscle or cervical rib.

Wright's: the patient’s arm is hyper-abducted. If there is a decrease or absence of a pulse on one side, then the test is positive, showing the axillary artery is compressed by the pectoralis minor muscle or coracoid process due to stretching of the neurovascular bundle.

Cyriax Release: the patient is seated or standing. The examiner stands behind the patient and grasps under the forearms, holding the elbows at 80 degrees of flexion with the forearms and wrists in neutral. The examiner leans the patient’s trunk posteriorly and passively elevates the shoulder girdle. This position is held for up to 3 minutes. The test is positive when paresthesia and/or numbness (release phenomenon) occur, including the reproduction of symptoms.

Supraclavicular pressure: the patient is seated with the arms at the side. The examiner places his fingers on the upper trapezius and his thumb on the anterior scalene muscle near the first rib. Then the examiner squeezes the fingers and thumb together for 30 seconds. If there is a reproduction of pain or paresthesia, the test is positive, which addresses the compromise to brachial plexus through scalene triangles.

Costoclavicular Maneuver: this test may be used for both neurological and vascular compromise. The patient brings his shoulders posteriorly and hyperflexes his chin. A decrease in symptoms means that the test is positive and that he neurogenic component of the neurovascular bundle is compressed.

Upper Limb Tension: These tests are designed to put stress on the neurological structures of the upper limb. The shoulder, elbow, forearm, wrist, and fingers are kept in a specific position to put stress on a particular nerve (nerve bias) and further modification in the position of each joint is done as a "sensitizer.".

Cervical Rotation Lateral Flexion: The test is performed with the patient sitting. The cervical spine is passively and maximally rotated away from the side being tested. While maintaining this position, the spine is gently flexed as far as possible moving the ear toward the chest. A test is considered positive when the lateral flexion movement is blocked.

Investigation

  • Electrophysiological studies
  • Imaging studies

Treatment

  • Nonsteroidal anti-inflammatory drugs have been prescribed to reduce pain and inflammation.
  • Botulinum injections to the anterior and middle scalenes have also been found to temporarily reduce pain and spasms from neurovascular compression, further research is needed because there are discrepancies in the literature. 

Surgical management of TOS should only be considered after conservative treatment has been proven ineffective. However, limb-threatening complications of vascular TOS have been indicated for surgical intervention. Surgery to treat thoracic outlet syndrome may be performed using several different approaches, including the trans-axillary approach, the supraclavicular approach, and the infraclavicular approach.

Transaxillary Approach

The first rib forms the common denominator for all causes of nerve and artery compression in this region, so its removal generally improves symptoms. The surgeon makes an incision in the chest to access the first rib, divides the muscles in front of the rib, and removes a portion of the first rib to relieve compression without disturbing the nerves or blood vessels.

Supraclavicular Approach

has been advocated to perform first rib resection and scalenectomy, a safe and effective procedure, characterized by a shorter operative time and having a complication rate lower or comparable to that of transaxillary first rib resection.
This approach repairs compressed blood vessels. The surgeon makes an incision just under the neck to expose the brachial plexus region. Then he looks for signs of trauma or muscles contributing to compression near the first rib. The first rib may be removed if necessary to relieve compression.

Infraclavicular  Approach

In this approach, the surgeon makes an incision under the collarbone and across the chest. This procedure may be used to treat compressed veins that require extensive repair.

Neurogenic TOS

Surgical decompression should be considered for those with true neurological signs or symptoms. These include weakness, wasting of the hand's intrinsic muscles, and conduction velocity less than 60 m/sec. The first rib can be a major contributor to TOS. There is controversy, however, regarding the necessity of a complete resection to reduce the chance of reattachment of the scalenes, scar tissue development, or bony growth of the remaining tissue. In addition to the first rib, cervical ribs are removed, splenectomies can be performed, and fibrous bands can be excised. Terzis found the supraclavicular approach to treatment to be an effective and precise surgical method

Arterial TOS

Decompression can include cervical and/or first rib removal and scalene muscle revision. The subclavian can then be inspected for degeneration, dilation, or aneurysm. A saphenous vein graft or synthetic prosthesis can then be used if necessary

Venous TOS

Thrombolytic therapy is the first line of treatment for these patients. Because of the risk of recurrence, many recommend that removal of the first rib is necessary even when thrombolytic therapy completely opens the vein. The results of a study show that the infraclavicular approach is a safe and effective treatment for acute VTOS. They had no brachial plexus or phrenic nerve injuries.
Angioplasty can then be used to treat those with venous stenosis

In venous or arterial TOS, medication can be administered to dissolve blood clots prior to thoracic outlet compression. It may also be to conduct a procedure to remove a clot from the vein or artery or repair the vein or artery prior to thoracic outlet decompression.

Some larger-chested women have sagging shoulders that increase pressure on the neurovascular structures in the thoracic outlet. A supportive bra with wide and posterior-crossing straps can help reduce tension. Extreme cases may resort to breast-reduction surgery to relieve TOS and other biomechanical problems

Physical Therapy Management

Conservative management should be the first strategy to treat TOS since this seems to be effective at decreasing symptoms, facilitating return to work, and improving function, but yet a few studies have evaluated the optimal exercise program as well as the difference between conservative management and no treatment. Conservative management includes physical therapy, which focuses mainly on patient education, pain control, range of motion, nerve gliding techniques, strengthening, and stretching.

Stage 1:

The aim of the initial stage is to decrease the patient’s symptoms. This may be achieved by patient education, in which TOS, bad postures, the prognosis, and the importance of therapy compliance are explained. Furthermore, some patients who sleep with their arms in an overhead, abducted position should get some information about their sleeping posture to avoid waking up at night. These patients should sleep on their uninvolved side or supine, potentially by pinning down the sleeves. The Cyriax release test may be used if a ‘release phenomenon’ is present. This technique completely unloads the neurovascular structures in the thoracic outlet before going to bed.

Cyriax Release Maneuver

  • Elbows flexed to 90°
  • Towels create a passive shoulder girdle elevation
  • Supported spine and the head in neutral
  • The position is held until peripheral symptoms are produced. The patient is encouraged to allow symptoms to occur as long as can be tolerated for up to 30 minutes, observing for a symptom decrescendo as time passes.

The patient’s breathing techniques need to be evaluated, as the scalenes and other accessory muscles often compensate to elevate the ribcage during inspiration. Encouraging diaphragmatic breathing will lessen the workload on already overused or tight scales and can possibly reduce symptoms.

Scapula Settings and Control

In the treatment, you first have to start with scapula settings and control.

This is important to establishing normal scapula muscle recruitment and control in the resting position. Once this is achieved, the program progresses to maintaining scapula control while both motion and load are applied. The programme begins in lower ranges of abduction and is gradually progressed further up into abduction and flexion ranges until muscles are being retrained in functional movement patterns at higher ranges of elevation.

Control the Humeral Head Position

It is also important to control the humeral head position. Specific drills are given to facilitate humeral head control. The most common aberrant position of the humeral head is an increase in anterior placement of the humeral head. A useful strategy to help facilitate co-contraction of the rotator cuff to help stabilize and centralize the humeral head is to facilitate a mid-level isometric contraction of the rotator cuff by applying resistance to the humeral head

(Dark et al., 2007)

Further on in the treatment, this may be integrated into movement patterns. First in slow controlled concentric/eccentric motion drills, later isolated muscle strengthening drills.

Serratus Anterior Recruitment and Control

Abduction external rotation strategies described above are often sufficient to trigger serratus anterior recruitment and control without the risk of over-activating pectoral minor muscle

Stage 2:

Once the patient has control over his/her symptoms, the patient can move to this stage of treatment. The goal of this stage is to directly address the tissues that create structural limitations of motion and compression. How this should be done is one of the most discussed topics of this pathology. Some examples of methods that are used in the literature are.

  • Massage
  • Strengthening of the levator scapulae, sternocleidomastoid and upper trapezius (This group of muscles open the thoracic outlet by raising the shoulder girdle and opening the costoclavicular space)
  • Stretching of the pectoralis, lower trapezius and scalene muscles (These muscles close the thoracic outlet)
  • Postural correction exercises
  • Relaxation of shortened muscles 
  • Aerobic exercises in a daily home exercise program:

Exercises

Shoulder exercises restore the range of motion and provide more space for the neurovascular structures.
Exercise: Lift your shoulders backward and up, flex your upper thoracic spine, and move your shoulders forward and down. Then straighten the back and repeat 5 to 10 times.

ROM of the upper cervical spine
Exercise: Lower your chin 5 to 10 times against your chest, while standing with the back of your head against a wall. The effectiveness of this exercise can be increased by pressing the head down with your hands.

The activation of the scalene muscles is the most important exercise. These exercises help to normalize the function of the thoracic aperture as well as all the malfunctions of the first rib. Exercises are Anterior scalene (pressing your forehead 5 times against the palm of your hand for a duration of 5 seconds, without creating any movement), Middle scalene (pressing your head sideways against your palm), and posterior scalene (pressing your head backward against your palm).

Stretching exercises

Other Interventions

  • Repositioning/mobilization of the shoulder girdle and pelvis joints: cervicothoracic, sternoclavicular, acromioclavicular, and costotransverse joints 
  • Glenohumeral mobilizations in end-range elevation with the elbow supported in extension
  • Taping: some patients with severe symptoms respond to additional taping, adhesive bandages, or braces that elevate or retract the shoulder girdle.

Manipulative Treatment to Mobilize the First Rib

These should be carried out with caution and only after a thorough assessment, as they can provoke irritation and pain symptoms in some patients

  1. Posterior Glenohumeral Glide with Arm Flexion:
    The patient is supine. The mobilization hand contacts the proximal humerus, avoiding the coracoid process. The force is directed posterolaterally (direction of the thumb).
  2. Anterior Glenohumeral Glide with Arm Scaption:
    The patient is prone. The mobilization hand contacts the proximal humerus, avoiding the acromion process. The force is directed anteromedially.
  3. Inferior Glenohumeral Glide:
    The patient is prone. The stabilizing hand holds the proximal humerus, the humerus distal to the lateral acromion process. The mobilization hand contacts the axillary border of the scapula. Mobilize the scapula in a craniomedial direction along the ribcage.

Post-Op Physical Therapy

If a patient does require surgery, then physical therapy should follow immediately to prevent scar tissue and return the patient to full function.

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