1. Thoracic Outlet Syndrome

2. Normal Anatomy Thoracic Outlet: Neurovascular structures:
Interscalene triangle
Costoclavicular space
Subcoracoid Space
Neurovascular structures:
Brachial plexus
Subclavian vein
Subclavian artery

3. Pathophysiology
Compression or compromise of brachial plexus, subclavian artery or vein
Occurs at any of the 3 spaces in the thoracic outlet

4. Pathophysiology Symptoms depend upon which structures are compromised
Pain
Paraesthesia
Weakness
Discomfort in the upper limb
Vascular dysfunction

5. Mechanism Of Injury Traumatic Insidious Rare Whiplash Fractures
Crush injury
Insidious
Congenial abnormalities
Postural
Repetitive overuse
Soft tissue adaptions

6. Classification

7. Associated Pathologies
Whiplash Associated Disorder
Chronic Obstructive Pulmonary Disease
Presence of cervical rib
Deformity of first rib
Deformity of C7 transverse process
Fracture clavicle, sternum or acromioclavicular joint.

8. Subjective Aged 20-50 years
More females than men (ratio from 2:1 and 4:1)
Unilateral symptoms
Pain
Paraesthesia
Weakness
Change in skin colour and temperature
Reduction of arterial pulse
Aggravated by sustained shoulder elevation, suspensory holding activities, lying on the arm, carrying a handbag or prolonged postures.
Pain wakes them at night

9. Objective Abnormal posture Restricted and painful ROM
Pain on sustained arm elevation
Poor scapular positioning at rest and moving
Change in skin temperature
Change in sensation
Change in power
Hypermobility or hypermobility of cervical, thoracic or upper limb joints.
Tightness and pain on palpation of surrounding soft tissues

10. Thoracic Outlet Syndrome
Cervical Radiculopathy

11. Special Tests Adson’s Test Wright’s Test Roos Test The military brace
Postural and scapular corrective exercises
Tinnels at the supraclavicular fossa
Morley Test

12. Further Investigation
Chest X-Ray with or without angiography (vascular)
MRI
Ultrasound with Doppler
Nerve conduction studies
Anterior scalene block

13. General Management Dependant upon classification
Neural
Vascular
Unlikely to treat vascular, may need onward referral
Treatment based on assessment
Difficult to treat due to misdiagnosis

14. Conservative - Management
Advice for posture, activity modification, avoiding aggravating factors and pain
Reduce pain, swelling and inflammation
Medications (opioids, NSAIDs); Ice and or heat; Light soft tissue massage; Taping for postural management
Increase Range of Movement
Decrease tone
Soft tissue massage: paraspinals, scalenes, trapezius, pectoralis minor, pathway of peripheral nerves
Diaphragmatic breathing (offloads scalenes)
Stretching
Light ROM exercises
Dry needling
Improve Joint Movement
Joint mobs: cervical spine, thoracic spine, glenohumeral joint, first rib
Soft tissue massage
Manipulations
Exercise

15. Conservative Management
Restore Normal motor control and strength
Deep neck flexors, scapular control and mobility, core stability, shoulder dynamic stability (rotator cuff)
Restore dynamic stability and proprioception
Strengthen under load, improve scapular mobility throughout range, sport and activity specific

16. Plan B - Management
Dependant upon type of TOS; may need thromboectomy or anticoagulation if vascular
Surgery rarely performed
Removal of congenital abnormalities
Scalene or pec minor release