Thoracic Outlet Syndrome: Difference between revisions
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'''Malfunction of the first rib''': isometric contraction of scalenus anterior and medius results in elevation of the first rib anteriorly, and reduces posterior subluxation. The therapist places their hand over the lateral head with the patient in a seated position. The patient contracts against the therapists hand. Gentle mobilisations are done over 20 seconds. | '''Malfunction of the first rib''': isometric contraction of scalenus anterior and medius results in elevation of the first rib anteriorly, and reduces posterior subluxation. The therapist places their hand over the lateral head with the patient in a seated position. The patient contracts against the therapists hand. Gentle mobilisations are done over 20 seconds. | ||
'''Postural dysfunction:''' Spinal postural stability; release tight pectoralis minor, scalene and shoulder girdle muscles; maintain cervicothoracic mobility; strengthen scapula muscles, lower and middle trapezius, and serratus anterior; strengthen rotator cuff; address ergonomic factors; address work behaviour factors. | '''Postural dysfunction:''' Spinal postural stability; release tight pectoralis minor, scalene and shoulder girdle muscles (e.g. infraspinatus); maintain cervicothoracic mobility; strengthen scapula muscles, lower and middle trapezius, and serratus anterior; strengthen rotator cuff; address ergonomic factors; address work behaviour factors. | ||
== See Also == | == See Also == | ||
Revision as of 22:24, 18 February 2022
Anatomy
The upper thoracic aperture is bordered by
- Posteriorly - spine
- Anteriorly - manubrium
- Laterally - 1st rib
Aetiology
Various causes have been proposed including
- Anomalous scalene bands
- Anomaly or fracture of 1st rib
- Cervical rib
- Fracture clavicle
- 1st rib dysfunction. Subluxation cranially at the costotransverse joint leading to irritation of the nerve roots C8 and T1 as well as the stellate ganglion.
- Myofascial pain
Note that anomalies of the thoracic outlet are also common in asymptomatic individuals. In a study of 50 cadavers only 10% had a bilaterally normal anatomy.[1]
Clinical Features
History
The pain radiates from the shoulder to the chest. There is pain in the medial arm, lateral shoulder, upper arm, and dorsal forearm. Pain can occur at night.
Neurological symptoms occur with numbness and paraesthesias of the arm usually the medial arm and hand (4th and 5th fingers)
Symptoms are worse when working with the arm above horizontal. There may be swelling (tight rings), coldness and discoloration in the right arm/hand
There may be restricted abduction and internal rotation of the ipsilateral shoulder.
Examination
| Thoracic Outlet Syndrome Tests | |||||
|---|---|---|---|---|---|
| Test | Sensitivity | Specificity | +LR | -LR | Kappa |
| Cervical Rotation Lateral Flexion Test[3] | 0.92 | 0.90 | 9.2 | 0.09 | 1.0 |
| Both Adson + Wright (pulse) positive | 0.54 | 0.94 | 9.0 | 0.5 | |
| Both Adson + hyperabduction (sx) positive | 0.72 | 0.88 | 6 | 0.3 | |
| Hyperabduction (pulse abolition) | 0.52 | 0.90 | 5.2 | 0.5 | |
| Both Adson + Roos positive | 0.72 | 0.82 | 4 | 0.3 | |
| Both Adson + Wright (sx) positive | 0.79 | 0.76 | 3.3 | 0.3 | |
| Both Adson + Roos positive | 0.72 | 0.82 | 4 | 0.3 | |
| Adson test | 0.79 | 0.76 | 3.3 | 0.3 | |
| Tinel sign | 0.86 | 0.56 | 2.0 | 0.3 | |
| Both Wright (pulse) + hyperabduction (sx) positive | 0.63 | 0.69 | 2.0 | 0.5 | |
| Both Wright (sx) + hyperabduction (sx) positive | 0.83 | 0.50 | 1.7 | 0.3 | |
| Both Wright (sx) + Roos positive | 0.83 | 0.47 | 1.6 | 0.4 | |
| Wright test (pulse abolition) | 0.70 | 0.53 | 1.5 | 0.6 | |
| Hyperabduction (sx reproduction) | 0.84 | 0.40 | 1.4 | 0.4 | |
| Wright test (sx reproduction) | 0.90 | 0.29 | 1.3 | 0.3 | |
| Roos test | 0.84 | 0.30 | 1.2 | 0.5 | |
Treatment
Malfunction of the first rib: isometric contraction of scalenus anterior and medius results in elevation of the first rib anteriorly, and reduces posterior subluxation. The therapist places their hand over the lateral head with the patient in a seated position. The patient contracts against the therapists hand. Gentle mobilisations are done over 20 seconds.
Postural dysfunction: Spinal postural stability; release tight pectoralis minor, scalene and shoulder girdle muscles (e.g. infraspinatus); maintain cervicothoracic mobility; strengthen scapula muscles, lower and middle trapezius, and serratus anterior; strengthen rotator cuff; address ergonomic factors; address work behaviour factors.
See Also
Reporting standards are by Illig et al. [4]
References
- ↑ Juvonen T, Satta J, Laitala P, Luukkonen K, Nissinen J. Anomalies at the thoracic outlet are frequent in the general population. Am J Surg. 1995 Jul;170(1):33-7. doi: 10.1016/s0002-9610(99)80248-7. PMID: 7793491.
- ↑ Gillard et al.. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint bone spine 2001. 68:416-24. PMID: 11707008. DOI.
- ↑ Lindgren KA, Leino E, Manninen H. Cervical rotation lateral flexion test in brachialgia. Arch Phys Med Rehabil. 1992 Aug;73(8):735-7. PMID: 1642524.
- ↑ Illig et al.. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. Journal of vascular surgery 2016. 64:e23-35. PMID: 27565607. DOI.
Literature Review
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,
