38 Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Thoracic outlet syndrome is a neurovascular condition characterized by tingling, numbness and pain in the shoulder and upper extremity, hand and fingers.

Pathophysiology

Symptoms are often the result of irritation or compression at the thoracic outlet (three structures are at risk: the brachial plexus, the subclavian vein, and the subclavian artery). Compression of these structures is classified as neurogenic (NTOS), venous (VTOS), and arterial (ATOS) thoracic outlet syndromes. Although each of these three are separate entities, multiple sites of compression can coexist and have overlapping symptoms.


Osmosis: Klumpke’s palsy and thoracic outlet syndrome


Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient-specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • DASH Outcome Measure
  • Upper Extremity Functional Index

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Spurling’s Test (Foraminal Compression Test)
  • Cervical Distraction Test
  • Cervical Compression Test
  • Scalene Cramp Test
  • Adson’s Test
  • Halstead Maneuver (Reverse Adson’s Test or Wright’s Test or Hyperabduction Test)
  • Costoclavicular Test (Military Brace)
  • Upper Limb Tension Tests (1, 2, 3, & 4)
  • Tinel’s Sign

Ariella.Studies – Injuries Associated with The Brachial Plexus

The Brachial Plexus
Injuries associated with the brachial plexus.

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

The responses to massage therapy are complex and multifactorial – physiological and psychological factors interplay in a complex manner. Massage therapy combined with multimodal care may improve symptoms, decrease disability and improve function for patients who suffer from mild forms of thoracic outlet syndrome. Massage has a modulating effect on peripheral and central processes via input from large sensory neurons that prevents the spinal cord from amplifying the nociceptive signal. This anti-nociceptive effect of massage therapy can help ease discomfort in patients who suffer from peripheral nerve entrapment.

Structures to be Aware of When Treating Thoracic Outlet Syndrome
A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from thoracic outlet syndrome may include neurovascular structures and investing fascia of:

  • Interscalene Triangle (anterior scalene muscle, middle scalene muscle, and first rib)
  • Costoclavicular Space (subclavius muscle, clavicle, the first rib, and anterior scalene muscle)
  • Subcoracoid Space (pectoralis minor muscle, and the ribs)
  • The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)
  • Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris)
  • Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris)
  • Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as stretching, splinting and home exercises may be  useful for people with thoracic outlet syndrome.

Prognosis

Prognosis for the conservative management of thoracic outlet syndrome is mixed. Massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for patients with thoracic outlet syndrome including soft tissue massage, simple home-care recommendations and remedial exercise. It is not suggested that massage therapy alone can control symptoms but be can used to help relieve pain & reduce anxiety when integrated with standard care.


Massage Tutorial: Thoracic outlet syndrome, tingling fingers, myofascial release


Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for thoracic outlet syndrome based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 47(9), 593–615. doi:10.2519/jospt.2017.7117

Buller, L. T., Jose, J., Baraga, M., & Lesniak, B. (2015). Thoracic Outlet Syndrome: Current Concepts, Imaging Features, and Therapeutic Strategies. American journal of orthopedics (Belle Mead, N.J.), 44(8), 376–382.

Greening, J., Anantharaman, K., Young, R., & Dilley, A. (2018). Evidence for Increased Magnetic Resonance Imaging Signal Intensity and Morphological Changes in the Brachial Plexus and Median Nerves of Patients With Chronic Arm and Neck Pain Following Whiplash Injury. The Journal of orthopaedic and sports physical therapy, 48(7), 523–532. doi:10.2519/jospt.2018.7875

Hixson, K. M., Horris, H. B., McLeod, T., & Bacon, C. (2017). The Diagnostic Accuracy of Clinical Diagnostic Tests for Thoracic Outlet Syndrome. Journal of sport rehabilitation, 26(5), 459–465. doi:10.1123/jsr.2016-0051

Illig, K. A., Donahue, D., Duncan, A., Freischlag, J., Gelabert, H., Johansen, K., … Thompson, R. (2016). Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. Journal of vascular surgery, 64(3), e23–e35. doi:10.1016/j.jvs.2016.04.039

Jesson, T., Runge, N., & Schmid, A. B. (2020). Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety. PAIN Reports, 5(5), 1-e834

Jones, M. R., Prabhakar, A., Viswanath, O., Urits, I., Green, J. B., Kendrick, J. B., … Kaye, A. D. (2019). Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain and therapy, 8(1), 5–18. doi:10.1007/s40122-019-0124-2

Nee, R. J., Jull, G. A., Vicenzino, B., & Coppieters, M. W. (2012). The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain. The Journal of orthopaedic and sports physical therapy, 42(5), 413–424. doi:10.2519/jospt.2012.3988

Povlsen, S., & Povlsen, B. (2018). Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions. Diagnostics (Basel, Switzerland), 8(1), 21. doi:10.3390/diagnostics8010021

Saunders, R., Astifidis, R., Burke, S., Higgins, J., McClinton, M., (2015). Hand and Upper Extremity Rehabilitation: A Practical Guide (4th ed.). Elsevier

Schmid, A. B., Fundaun, J., & Tampin, B. (2020). Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain reports, 5(4), e829.https://doi.org/10.1097/PR9.0000000000000829

Skirven, T., Osterman, A. L., Fedorczyk, J., Amadio, P., Felder, S., Shin, E. (2021). Rehabilitation of the Hand and Upper Extremity (7th ed.). Elsevier

Spicher, C. (2020). Atlas of Cutaneous Branch Territories for the Diagnosis of Neuropathic Pain. Springer

Verenna, A. A., Alexandru, D., Karimi, A., Brown, J. M., Bove, G. M., Daly, F. J., … Barbe, M. F. (2016). Dorsal Scapular Artery Variations and Relationship to the Brachial Plexus, and a Related Thoracic Outlet Syndrome Case. Journal of brachial plexus and peripheral nerve injury, 11(1), e21–e28. doi:10.1055/s-0036-1583756

Wakefield, M. L. (2014). Case report: the effects of massage therapy on a woman with thoracic outlet syndrome. International journal of therapeutic massage & bodywork, 7(4), 7–14. doi:10.3822/ijtmb.v7i4.221

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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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