Thoracic Outlet Syndrome

adrian wong physio

Article by J. Miller, A. Wong

What is Thoracic Outlet Syndrome? 

thoracic outlet syndrome

Thoracic Outlet Syndrome is a complex condition in which blood vessels and/or nerves are entrapped or compressed as they exit the thorax. Thoracic Outlet Syndrome is caused by a compression of the brachial plexus or subclavian vessels as they exit the neck into the shoulder region and pass under the first rib. 

Anatomy of the Thoracic Outlet

The structures most commonly compromised in Thoracic Outlet Syndrome are:

  • subclavian artery
  • subclavian vein
  • lower roots of the brachial plexus (bundle of nerves supplying the upper body and arms) 

These structures may become compressed in 3 areas:

  • between the anterior and middle scalene muscles of the neck
  • between the collarbone and first rib
  • beneath the coracoid process of the shoulder blade

Types of Thoracic Outlet Syndrome

There are 2 main classifications of Thoracic Outlet Syndrome: Vascular & Neurological 

Vascular Thoracic Outlet Syndrome

  • 2% of cases
  • Compression of the blood vessels exiting the thorax (subclavian artery or vein)

Neurological Thoracic Outlet Syndrome

  • 98% of cases
1. True Neurological Thoracic Outlet Syndrome: 
  • Compression of nerves exiting thorax due to bony or soft tissue anomaly.
2. Symptomatic Thoracic Outlet Syndrome: 
  • Intermittent compression of nerves and blood vessels due to repetitive postural, occupational or sporting forces (Watson et al., 2009)

Thoracic Outlet Syndrome Symptoms

Thoracic Outlet Syndrome is characterised by:
  • Pain, altered sensation and weakness of the upper limb. 
  • Pain or discomfort is often felt above or below the collarbone and may radiate down the arm. 
  • Altered sensation and temperature in the arm and hand is also associated with this condition. 
  • Symptoms are generally aggravated or exacerbated by lifting your arm or turning your head or neck (Lindgren & Oksala, 1995).

Symptoms vary and are often difficult to differentiate from other shoulder aetiologies such as rotator cuff pathology or cervical radiculopathy (pinched nerve). 

Vascular Thoracic Outlet Syndrome

  • Pins & needles, numbness in arm and hand
  • Decreased or absent arterial pulse 
  • Swelling, coldness, colour change in arm and hand
  • Feeling of stiffness, heaviness fatigue in arm (Watson et al., 2009)

Neurological Thoracic Outlet Syndrome

  • Pain in neck, collar bone region, chest, upper back, shoulder, arm, hand
  • Pins & needles, numbness in fingers 
  • Weakness of arm and hand
  • Loss of dexterity/coordination in hand
  • Muscle spasms in arm/hand
  • Feeling of stiffness, heaviness fatigue in arm
  • Pain at rest and night pain
  • Less commonly dizziness, headaches, vertigo (Watson et al., 2009)

Risk Factors for Thoracic Outlet Syndrome

  • Bony abnormalities, eg. abnormal first rib, cervical rib
  • Trauma
  • Poor posture
  • Jobs or sporting activities involving repetitive overhead movements
  • Weight gain

Common Thoracic Outlet Findings

Symptoms may increase with overhead ranges of motion on examination. You may also have a positive: Costoclavicular manouever, Roo's test or Adson’s test. 

If you suspect thoracic outlet syndrome, you may consider cervical spine X-rays to evaluate for the presence of a cervical rib, or prominent C7 transverse process that may be contributing to the symptoms. Additional tests (e.g., MRI, EMG) can be used to rule out other causes. 

Physiotherapy Treatment of Thoracic Outlet Syndrome

  • Postural advice and education
  • Ergonomic assessment and intervention 
  • Rest from aggravating activities
  • Correction of ‘dropped shoulder’ position (Watson et al., 2010)
  • Strengthening of shoulder blade stabilising muscles
  • Mobilisation of thoracic spine and first rib
  • Massage of neck, chest and upper back muscles
  • Neural gliding exercises

Surgery should only be considered if conservative treatment fails (MacKinnon & Novak, 2002)

For more specific information, please seek the advice of your physiotherapist.

Thoracic Outlet Syndrome Treatment Options

Thoracic outlet treatment will vary significantly depending on the structure causing your symptoms. Please consult your doctor or physiotherapist for specific thoracic outlet syndrome treatment.

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Treatment Options

  • Bed Rest
  • Early Injury Treatment
  • Avoid the HARM Factors
  • What to do after a Muscle Strain or Ligament Sprain?
  • Acupuncture and Dry Needling
  • Sub-Acute Soft Tissue Injury Treatment
  • Scapular Stabilisation Exercises
  • Closed Kinetic Chain Exercises
  • Biomechanical Analysis
  • Proprioception & Balance Exercises
  • Medications?
  • Ergonomics
  • Soft Tissue Massage
  • Brace or Support
  • Deep Neck Stabilisation Exercises
  • Dry Needling
  • Electrotherapy & Local Modalities
  • Heat Packs
  • Joint Mobilisation Techniques
  • Kinesiology Tape
  • Neurodynamics
  • Physiotherapy Instrument Mobilisation (PIM)
  • Prehabilitation
  • Strength Exercises
  • Stretching Exercises
  • Supportive Taping & Strapping
  • TENS Machine
  • Video Analysis
  • Yoga
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    Last updated 25-Apr-2018 04:19 PM

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