Thoracic Outlet Syndrome

Aka: Thoracic Outlet Syndrome

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II. Causes

  1. Costoclavicular Syndrome
  2. Cervical Rib Syndrome
  3. Hyperabduction Syndrome
  4. Scalenus Anticus Syndrome

III. Symptoms

  1. Neural Involvement (95%)
    1. Ulnar Nerve is the most commonly affected structure
    2. Extremity pain
    3. Extremity numbness
  2. Venous Involvement (4%)
    1. Distal extremity swelling
  3. Arterial Involvement (1%)
    1. Extremity falls asleep
    2. Glove distribution with or without paresis

IV. Exam

  1. Sensory and Motor Exam
  2. Specific provocative maneuvers
    1. Adson's Test
    2. Costoclavicular Maneuver
    3. Wright's Test
    4. Elevated Arm Stress Test (Roos Stress Test, EAST Test)

V. Differential Diagnosis

  1. Cervical Radiculopathy
  2. Brachial Plexus Injury
  3. Distal Peripheral Neuropathy
    1. Median Neuropathy
    2. Radial Neuropathy
    3. Ulnar Neuropathy

VI. Management: Conservative (Physical Therapy)

  1. See specific conditions
  2. Elevate Shoulder
    1. Rest on arm of chair
    2. Sling
  3. Pendulum Shoulder Exercises
  4. Moist heat and Ultrasound
  5. Strengthening Exercises for Shoulder girdle Muscles
    1. Trapezius Muscle
      1. Shoulder shrug with weight
    2. Serratus anterior
      1. Bench Press, lifting Shoulders from table
  6. Correct faulty Posture
  7. Avoid positions that exacerbate symptoms

VII. Management: Surgery

  1. Indications
    1. Vascular compromise (rare)
    2. Conservative management fails after 4-6 months
  2. Surgery (Consider after conservative Rx fails x4-6mo)
    1. Removal of first dorsal and cervical ribs
    2. Release of abnormal scalene Muscle insertions
    3. Vascular repair

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