Thoracic Outlet Syndrome
Thoracic Outlet Syndrome (TOS) is a condition that is characterized by shoulder and arm pain, tingling, or numbness caused irritation to the neurovascular structures in the thoracic outlet. Most TOS patients suffer from mechanical compression of the neurovascular bundle or “Neurogenic TOS”. Neurogenic TOS is by far the most common cause of TOS, accounting for well over 95% of all cases. Neurogenic TOS results from compression or irritation to the brachial plexus (2). TOS is subdivided into one of three primary sites of compression. “Scalene” induced TOS occurs from compression of the neurovascular bundle between the anterior and middle scalene muscles. “Pectoral” compression occurs beneath the pectoralis minor tendon. “Costoclavicular” compression happens between the first rib and clavicle. Poor posture, especially upper crossed syndrome, is a predisposing factor for all mechanical forms of TOS. Static postures such as those required by computer users, assembly line workers, supermarket checkers, and students predispose to TOS, as do occupations requiring prolonged overhead activity, i.e., electricians and painters. Swimmers, volleyball players, tennis players, and baseball pitchers are subject to predisposing stressors. Who gets TOS?
Most patients presenting with TOS are between the ages of 20-60, with a peak incidence in the fourth decade (6). TOS is more common in women with some estimates as high as 9:1 (7). Clinical Presentation : Symptoms of TOS include pain, shoulder and arm paresthesias, and weakness. Neck, arm and hand pain is often aggravated by lifting of the arms or excessive head and neck movement. A thorough neurological evaluation will help establish the diagnosis and rule out other conditions. Symptoms follow an ulnar nerve distribution in 90% of cases. (9) Motor deficits, especially diminished grip strength is possible (10). Diagnostics & Differential Additional diagnostic workup for TOS is dependent upon clinical presentation. Treatment options:
In the absence of acute or threatening neurovascular problems, conservative care should be the treatment of choice for TOS (13).
Joint manipulation may be indicated for restrictions in the cervical spine, first rib, cervicothoracic junction, shoulder, elbow, hand, and wrist.
Stretching and myofascial release techniques should address problems in the cervical spine, scalenes and pectoral muscles as well as distal sites
Retraining of postural faults and diaphragmatic breathing is critical.
Nerve mobilization, particularly for the ulnar nerve, will likely play a role in recovery (14). Lifestyle modifications:
Lifestyle modifications may include avoidance of repetitive postural stress and workstation modification. Patients should avoid carrying heavy loads, especially on their shoulder. Briefcases, laptop cases or heavy shoulder bags should be lightened. Bra straps may need additional padding or consideration of replacement with a sports bra. Surgical outcomes:
Surgical treatment of TOS remains controversial. (15) Studies have shown that candidates who undergo surgical resection do not have functional improvements matching those who choose conservative care (16). Other studies have shown good surgical outcomes (90%) when conservative measures have failed for neurogenic TOS patients (20).
At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
1. Elsevier, Thoracic Outlet Syndrome, www.clinicalkey.com (2013)
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8. Lindgren, 1997 K.A. Lindgren Conservative treatment of thoracic outlet syndrome: a 2-year follow-up Archives of Physical Medicine and Rehabilitation, 78 (4) (1997), pp. 373–378
9. thoracicoutletsyndromes.com (2013)
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11. Seror, 2005 P. Seror Frequency of neurogenic thoracic outlet syndrome in patients with definite carpal tunnel syndrome: an electrophysiological evaluation in 100 women Clinical Neurophysiology, 116 (2) (2005), pp. 259–263
12. D.B. Roos, J.C. Owens Thoracic outlet syndrome Archives of Surgery, 93 (1) (1966), pp. 71–74
13. Sharp WJ, Nowak LR, Zamani T, Kresowik TF, Hoballah JJ, Ballinger BA, et al. Long- term follow-up and patient satisfaction after surgery for thoracic outlet syndrome. Annals of Vascular Surgery 2001;15(1):32 e 6.
14. Mackinnon SE, Novak CB. Thoracic outlet syndrome. Current Problems in Surgery 2002;39(11):1070 e145
15. R. Degeorges, C. Reynaud, J.P. Becquemin Thoracic outlet syndrome surgery: long-term functional results Annals of Vascular Surgery, 18 (5) (2004), pp. 558–565
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18. Horris HB et al. The Diagnostic Accuracy of Clinical Diagnostic Tests for Thoracic Outlet Syndrome. Journal of Sport Rehabilitation, 2017, vol. 26, issue 5, p 459
20. Balderman J et al. Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2019 Mar 6. pii: S0741-5214(19)30169-7. doi: 10.1016/j.jvs.2018.12.027. [Epub ahead of print]