THORACIC OUTLET SYNDROME PHYSIOTHERAPY MISSISSAUGA
Updated: Nov 13, 2019
The term ‘thoracic outlet syndrome’ describes compression of the neurovascular structures as they exit through the thoracic outlet (cervicothoracobrachial region).
Different regions where it could lead to a compression of the nerve.
1. The first narrowing area is the most proximal and is named the interscalene triangle, near to the front of the neck between two fibers of the scalene
2. The second passageway is called the costoclavicular triangle which is bordered in-between the scapula, first rib, and the border of scapula.
3. The last passageway is called the subcoracoid or sub-pectoralis minor space minor tendon. Shortening of the pecoralis minor muscle can lead to a narrowing of the passage thereby compressing the neurovascular structures during excessive arm movements.
Certain anatomical abnormalities can be potentially compromising to the thoracic outlet as well. These include the presence of a cervical rib, congenital soft tissue abnormalities, clavicular hypomobility, and functionally acquired anatomical changes.
Causes:
• 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 uni- or bilateral elevated scapula
• Location of the A. or V. Subclavian in relation to the M. scalene anterior
• Postural factors
• Dropped shoulder condition.
• Wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine)
• Heavy chested.
• Trauma.
• Clavicle fracture.
• Rib fracture.
• Hyperextension neck injury, whiplash.
• Repetitive stress injuries (repetitive injury most often form 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, pectoral muscles.
Characteristics / Clinical Presentation
Diagnostic Procedures
The diagnosis of TOS is essentially based on history, physical examination, provocative tests, and if needed ultrasound, radiological evaluation and electrodiagnostic evaluation. It must always kept in mind that TOS diagnosis is usually confirmed by elimination of other causes with similar clinical presentation. Especially differential diagnosis of cervical radiculopathies and upper extremity entrapment neuropathies can be hard (McGillicuddy 2004). In order to diagnose accurately, the clinical presentation must be evaluated as either neurogenic (compression of the brachial plexus) or vascular (compression of the subclavian vessels). TOS manifestations are varied and there is no single definitive test, which makes it difficult to diagnose.
Neurological Screen
· MMT & Flexibility of following muscles:
– Scalene – Pectoralis major/minor – Levator scapulae – Sternocleidomastoid when the lateral flexion movement is blocked.
Physiotherapy Management
Conservative physiotherapy 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.
Few studies have evaluated the optimal physiotherapy exercise program as well as the difference between a conservative management and no treatment. Conservative management includes physical therapy, which focuses mainly on patient education, pain control, and range of motion, nerve gliding techniques, strengthening and stretching.
The aim of the initial stage of physiotherapy 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 the 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 in supine, potentially by pinning down the sleeves.
Also cervical traction in combination with a hot pack and light exercise may reduce pain and irritable symptoms for some acute patients.
Our physiotherapists usually do a proper assessment to educate you about the root cause of the problem. They may recommend proper ergonomic positioning or Postural brace to speed up the process of recovery.
If you have any of the above symptoms call us now and book an appointment with our physiotherapist today @ 905 997 4333
Registered Physiotherapist
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THORACIC OUTLET SYNDROME PHYSIOTHERAPY MISSISSAUGA
Updated: Nov 13, 2019
The term ‘thoracic outlet syndrome’ describes compression of the neurovascular structures as they exit through the thoracic outlet (cervicothoracobrachial region).
Different regions where it could lead to a compression of the nerve.
1. The first narrowing area is the most proximal and is named the interscalene triangle, near to the front of the neck between two fibers of the scalene
2. The second passageway is called the costoclavicular triangle which is bordered in-between the scapula, first rib, and the border of scapula.
3. The last passageway is called the subcoracoid or sub-pectoralis minor space minor tendon. Shortening of the pecoralis minor muscle can lead to a narrowing of the passage thereby compressing the neurovascular structures during excessive arm movements.
Certain anatomical abnormalities can be potentially compromising to the thoracic outlet as well. These include the presence of a cervical rib, congenital soft tissue abnormalities, clavicular hypomobility, and functionally acquired anatomical changes.
Causes:
• 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 uni- or bilateral elevated scapula
• Location of the A. or V. Subclavian in relation to the M. scalene anterior
• Postural factors
• Dropped shoulder condition.
• Wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine)
• Heavy chested.
• Trauma.
• Clavicle fracture.
• Rib fracture.
• Hyperextension neck injury, whiplash.
• Repetitive stress injuries (repetitive injury most often form 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, pectoral muscles.
Characteristics / Clinical Presentation
Diagnostic Procedures
The diagnosis of TOS is essentially based on history, physical examination, provocative tests, and if needed ultrasound, radiological evaluation and electrodiagnostic evaluation. It must always kept in mind that TOS diagnosis is usually confirmed by elimination of other causes with similar clinical presentation. Especially differential diagnosis of cervical radiculopathies and upper extremity entrapment neuropathies can be hard (McGillicuddy 2004). In order to diagnose accurately, the clinical presentation must be evaluated as either neurogenic (compression of the brachial plexus) or vascular (compression of the subclavian vessels). TOS manifestations are varied and there is no single definitive test, which makes it difficult to diagnose.
Neurological Screen
· MMT & Flexibility of following muscles:
– Scalene – Pectoralis major/minor – Levator scapulae – Sternocleidomastoid when the lateral flexion movement is blocked.
Physiotherapy Management
Conservative physiotherapy 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.
Few studies have evaluated the optimal physiotherapy exercise program as well as the difference between a conservative management and no treatment. Conservative management includes physical therapy, which focuses mainly on patient education, pain control, and range of motion, nerve gliding techniques, strengthening and stretching.
The aim of the initial stage of physiotherapy 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 the 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 in supine, potentially by pinning down the sleeves.
Also cervical traction in combination with a hot pack and light exercise may reduce pain and irritable symptoms for some acute patients.
Our physiotherapists usually do a proper assessment to educate you about the root cause of the problem. They may recommend proper ergonomic positioning or Postural brace to speed up the process of recovery.
If you have any of the above symptoms call us now and book an appointment with our physiotherapist today @ 905 997 4333
Registered Physiotherapist
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