Thoracic outlet syndrome (TOS) is a potentially painful and disabling condition of the upper extremity that is often overlooked and misunderstood. TOS is a condition in which the thoracic outlet, the space between the clavicle and first rib, is compromised/compressed. Within the thoracic outlet lie blood vessels, muscles and nerves. Due to the complexity of the structures involved, TOS is often misdiagnosed and mistreated.
Symptoms of TOS vary greatly among the TOS classifications. There are four common types of TOS that are classified based on type of structures compressed: Arterial, Venous, True Neurogenic and Disputed Neurogenic. Arterial TOS presents with pain in the hand but not in the neck and shoulder, cold intolerance, and pallor. Venous TOS presents with pain throughout the arm and swelling. Arterial and Venous TOS are considered vascular TOS and both are confirmed with Doppler, ultrasound or other imaging. True Neurogenic and Disputed Neurogenic TOS have severe symptoms in common, including shoulder pain, neck pain, numbness, cold intolerance, and headaches. True Neurogenic TOS presents with objectively measured weakness, impaired sensation, greater symptoms during the day than at night, and positive provocation and neurophysiological testing. Disputed Neurogenic TOS presents with symptoms greater at night compared to day and is diagnosed based on history and two provocation tests, but neurophysiological tests are often normal.
Diagnosing TOS can be challenging due to the variety of symptoms between patients. True and Disputed Neurogenic TOS are the most difficult to diagnose because of the objective tests and clinical impressions. A thorough patient history and clinical examination may help guide the diagnosis. Neurogenic TOS commonly develops following macro-trauma to the neck or shoulder girdle area such as a motor vehicle accident or repetitive activities. Clinical testing includes clavicle mobility assessment, first rib mobility and special tests such as the elevated arm test and Adison’s Test. Due to the complex nature of TOS, a patient may present as both a neurological and a vascular condition.
Once a TOS diagnosis has been confirmed, a treatment plan can be created. Conservative treatment may include physical therapy, nonsteroidal anti-inflammatory medications and weight loss. Physical therapy can be effective for managing symptoms and improving function. Physical therapy would involve education on the diagnosis, manual therapy to mobilize soft tissue, nerves and joints, strengthening exercises to provide support to the shoulder girdle, stretching exercises, neural mobility, postural exercises, sleep positioning education, work place modification and activity modification to minimize repetitive stress on the thoracic outlet. Conservative treatment is most beneficial for treatment of Disputed and True Neurogenic TOS. Surgical intervention is reserved for the TOS cases for which conservative measures have failed. Vascular TOS may require surgery to relieve compression on vital vascular structures.
TOS is a condition surrounded by confusion. It is a manageable and treatable condition with the appropriate assessment, diagnosis, education and treatment plan. Please contact your closest ApexNetwork Physical Therapy clinic for your Thoracic Outlet Syndrome treatment needs.
References: http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=068e8205-a221-46d0-8202-c3e6a5a9700d https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101069/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109687/ http://orthoinfo.aaos.org/topic.cfm?topic=A00336