Thoracic Outlet Syndrome - Tallahassee, FL€¦ · THORACIC OUTLET SYNDROME John Broussard, DO...
Transcript of Thoracic Outlet Syndrome - Tallahassee, FL€¦ · THORACIC OUTLET SYNDROME John Broussard, DO...
THORACIC OUTLET SYNDROME John Broussard, DO Sports Medicine Fellow Institute for Non-Surgical Orthopedics Larkin Community Hospital
Definition • A group of syndromes in which biomechanical
obstructions are believed to compress or obstruct structures in the thoracic outlet
• Subclavian artery & vein • Axillary artery • Cords of brachial plexus
TOS Symptoms • Arterial
• Numbness of arms/hands • Tingling of arms/hands • Positional weakness • Discoloration (pale/white hands)
• Venous • Swelling of fingers and hands • Heaviness of UEs • Discoloration (blue)
• Nerves • UE pain • Paresthesias of ulnar distribution • Weakness of hands • Clumsiness of hands • Coldness of hands • Tiredness, heaviness and
paresthesias on elevation of UEs
• Shoulder and Neck • Pain • Tightness
• Chest Wall • Anginal chest pain (heavy or
squeezing in midsternal area of chest)
• Inter/para-scapular pain (along medial shoulder blade)
• Head • Headaches • “funny feelings” in face and ear
• Vertebral Artery • Dizziness • Lightheadedness
Anatomy • Thoracic outlet? • Borders
• Anteriorly: manubrium • Posteriorly: Body of T1 • Laterally: 1st and 2nd ribs (and their costal cartilage)
• Articulations • Acromioclavicular • Sternoclavicular
Anatomy • “Sibson’s Fascia” = cervico-thoracic fascia
• Runs from root of neck lower boundary of axilla • (TP C7-border of rib 1)
• Tightly confines the neurovascular supply to the arm • Great lymph channels (ascending and descending terminal ducts)
pass through Sibson’s fascia.
Anatomy • Neurovascular bundle
• Subclavian a. (b/w 1st rib and scalenes) • Subclavian v. (anterior to anterior scalene) • Brachial plexus (C5-T1) (more post. and lateral to subclavian a.)
Innervation • Sympathetic
• Brachial plexus (C7-T1): shoulder girdle and upper extremity • T1-T4: head, neck & brain • T1-T8: upper extremity • T1-T6: heart & lungs
• Parasympathetic • Vagus: heart, lungs, upper GI, kidneys
Etiology • All TOSs occur due to a disruption or alteration of the
normal anatomy of the thoracic outlet. • Symptoms of TOS are DIRECTLY related to the structures
disrupted: • Shoulder or arm pain • Weakness • Paresthesias • Claudication • Raynaud’s phenomenon • Ischemic tissue loss • Gangrene
Predisposing Factors to TOS • Intrinsic:
• Anterior scalene tightness • Nerve root irritation, spondylosis, facet joint inflammation muscle spasm
• Pectoralis minor tightness • Repetitive overhead activity (shoulder elevation & hyperabduction)
• Costoclavicular approximation (b/w clavicle, 1st rib, support structures) • Postural deficiencies or carrying heavy objects
• Cervical ribs • Slender body habitus
• Extrinsic • Trauma (contusion, hematoma, clavicular fx, whiplash) • Unusual sleeping positions • Occupations w/ unusual arm postures
• Painters, mechanics, military recruits, backpackers, students • Athletes
• Swimmers, baseball pitchers, volleyball players, tennis players
Compression of neurovascular bundle • 3 locations:
• b/w anterior and middle scalenes • b/w clavicle and 1st rib • b/w pectoralis minor and upper ribs
DDx of TOS • Cervical nerve root compression (radiculopathy) • Pancoast Tumor (lung apex reaches 2/3 cm into neck) • Simple SD of ribs, clavicles, cervicals, thoracic spine • Neurofibromas • Cervical spondylosis • Cervical disc herniation • Carpal tunnel syndrome
• **Any/all may coexist w/ TOS**
Provocative Tests for TOS • Adson’s Test (b/w scalenes) • Costoclavicular (Military posture) test (b/w clavicle & 1st rib) • Hyperabduction test (under pectoralis minor) • Roos Test (Elevated Arm Stress Test)
• ER shoulders, elbows behind head. Open/close hands slowly x3 min. • Pos: pain, heaviness or profound arm weakness or tingling/numbness
• Spurling Test (not specific for TOS)
Adson’s Test Costoclavicular Test Roos Test
Treatment Overview • Protocol
• Identify type and cause of compression • Optimize normal function and treat all somatic dysfunction
• Suggestions • Exercise—stretching program • Correct biomechanics—assess daily life movements of patient
• “Why now?” • Meds: muscle relaxants, NSAIDs, Botox • Biofeedback • OMT • Massage • Physical Therapy • Yoga
Treatment: OMT • Myofascial release of thoracic outlet • Normalize vertebral SD (C2-C7 and upper thoracics) • Upper ribs (1st rib superior subluxation w/ shortening of
scalene muscles) • Appendages (SC, AC, GH) • Lymphatic treatment increase lymph flow • TPIs • Spray and stretch • Acupuncture
OMT • Upper Thoracic HVLA
• Chin pivot thrust • Dysfunction: T1 FRLSL • Patient in prone position w/ chin on table • Stand at head of patient, opposite to posterior
TP. • Place left hypothenar eminence on left TP of T1. • With right hand, SB pt’s head to the right to max
tissue tension while maintaining chin on table. • Rotate head away to obtain max tissue tension. • During exhalation, apply HVLA thrust w/ left hand
directed anteriorly, laterally, and inferiorly while stabilizing the head w/ right hand.
• Recheck.
OMT • SD: 1st Rib inhalation
• Still Technique • Patient supine. • Standing at side of patient on side of dysfuntion. • Flex pt’s elbow and place their palm on chest. • Place pads of index finger on pt’s 1st rib. • Using opposite hand, grasp the elbow and apply
longitudinal compression through humerus. • Using the elbow as a lever, pt’s arm is circumducted
clockwise by moving UE medially until elbow lines up w/ head of pt’s 1st rib.
• The arc of motion from this position is lateral and inferior, continuing circumduction motion, and compression, w/ patient’s arm ending at the midaxillary line.
• Recheck.
OMT • Anterior & Middle Scalenes
• O: TP C2-C7 • I: 1st Rib • A: Flexion and sidebending of C-spine
• Counterstrain • Find the tender point, wrap around it. • Hint: Follow the action of the muscle. • Hold until tissues relax, passively return to resting. • Recheck. • May add traction and passively return to rest (Still)
if no improvement.
OMT
• Pectoralis minor muscle • O: Anterior surface ribs 3-5 • I: Via tendon to medial aspect of coracoid
process of scapula. (Part or all of tendon may transverse this process and continue into coracoacromial ligament)
• A: Scapula protraction, rotation of scapula downwards
• Counterstrain • Find the tender point, wrap around it. • Hold until tissues relax, passively return to
rest. • Recheck.
OMT • Cervicles
• Whichever you are comfortable with or patient (or tissues) will allow: • Counterstrain • Still’s • HVLA
• Caution against muscle energy
Treatment • Self-Stretching
• Scalenes and pectoral muscles • Hold 30 sec., 10 reps bid • WILL exacerbate symptoms • Pain (deep ache) should not persist after stretch released • Strengthening exercises for trapezius and levator scapulae
• Massage • Cross-friction (pec minor and scalenes) • Shoulder girdle
References • DiGiovanna E, Schiowitz S. An osteopathic approach to diagnosis and
treatment. Philadelphia; JB Lippincott Co, 1991:45-53. • Kai Y, Oyama M, Kurose S, et al. Neurogenic thoracic outlet syndrome in
whiplash injury. J Spinal Disord 2001;4:487-493. • Karageanes S. Principles of Manual Sports Medicine. LWW, 2005: 268-293. • Kulund DN. The injured athlete, 2nd ed. Philadelphia: JB Lippincott Co 1988.