This document presents information on thoracic outlet syndrome (TOS). It begins with definitions and descriptions of the thoracic outlet anatomy. It then discusses the contents and structures that pass through the thoracic outlet including the brachial plexus, subclavian artery, and subclavian vein. Etiology and classifications of TOS are outlined. The document provides details on physical exams used to diagnose TOS and differential diagnoses. Conservative management including exercises and manual therapy techniques are explained. Two research articles on manual therapy and scalene injections/stretching for TOS are summarized. Reference sources are listed at the end.

1. PRESENTED BY:
HEMANT AGGARWAL
MPT FINAL YEAR
(Musculoskeletal Disorders)
1801717120002
Submitted to:
DR. SHABNAM JOSHI

2. Introduction:
 The term ‘thoracic outlet syndrome’(TOS) was coined
by RM Peet in 1956
 It is simply defined as neurovascular symptoms in the
upper extremities due to pressure on the nerves and
vessels in the thoracic outlet area
 The specific structures compressed are usually the
nerves of the brachial plexus and occasionally the
subclavian artery or vein (Richard J. Sanders)

3. Thoracic outlet:
 The thoracic outlet has three anatomic compartments
I. Interscalene triangle: bordered anteriorly by the
anterior scalene muscle, posteriorly by the middle
scalene muscle, and inferiorly by the medial surface of
the first rib
II. Costoclavicular: lies b/w the clavicle and the first rib
posteromedially and the upper border of the scapula
posterolaterally
III. Retropectoralis minor spaces: lies inferior to the
coracoid process beneath the pectoralis minor tendon

4. Contents:
 Brachial Plexus
Interscalene
triangle
 Subclavian artery
 Subclavian Vein Costoclavicular
Retro-
pectoralis
minor
spaces

6. Etiology:
ANATOMICAL DEFECTS:
Bony abnormalities-
According to Sanders RJ, Hammond SL et al. 2006
Cervical rib
Long C7 transverse process
Abnormal bands, ligaments
Fracture clavicle/first rib
Exotosis (bony spur)
Tumor

7. Soft-tissue Abnormalities-
Variation in scalene origin and insertion
Atasoy et. al 2004, scalenus minimus, an accessory
muscle, can be found in 30-50%
Hypertrophy of the scalene musculature
Congenital anomalous ligaments or bands
Trauma and later scarring (Roos DB et. al 1996)
 costocoracoid ligament is implicated in venous
compression in Paget-Schroetter syndrome

8. Classification:
I. True neurogenic,
II. Arterial,
III. Venous,
IV. Traumatic neurovascular,
V. Nonspecific TOS
According to Sanders RJ, Hammond SL et al.,
Neurogenic TOS accounts for more than 90% of all
TOS cases, whereas vascular TOS constitutes 3% to 4%
of all cases
 Vascular TOS is seen equally in nonathletic men and
women, but neurogenic TOS is three to four times more
likely to occur in women than in men

9. Neurogenic TOS:
Symptoms:
• loss of dexterity, muscle spasm, and a feeling of
heaviness of the upper extremity
• pain or weakness in the dermatomes and myotomes
associated with C8 or T1 compression
• paresthesias or weakness of the hand and arm, as well
as pain involving the head, neck, shoulder, and back
• cold intolerance, Raynaud phenomenon, coldness of
the hand, and color changes as a result of sympathetic
overactivity as opposed to ischemia
• headaches, tinnitus, and vertigo also may be present

10. Venous TOS:
 also known as Paget-Schroetter syndrome
 caused by a spontaneous thrombosis of the subclavian or
axillary vein (mainly in swimming, tennis, and weight
lifting)
 the limb feels heavy and becomes edematous and possibly
even cyanotic
 patient may have neurologic features such as pain and
paresthesias because of the vascular insult rather than injury
to the nerve itself
Three most important factors:-
 hypertrophy of the pectoral muscle,
 fibrosis and thickening of the damaged vessel wall from
repetitive activity,
 damage to the intima of the vein leading to a thrombogenic

11. Arterial TOS:
 the least common form of TOS but may have the most
serious potential consequences to life or limb
 most likely from compression b/w the anterior scalene
muscle or a bony anomaly such as a cervical rib or
deformed first thoracic rib
 Kee et al. reported on ischemia of the throwing hand in
professional baseball pitchers because of an embolic
occlusion from an axillary artery branch aneurysm
 Rohrer et al. showed that the subclavian or axillary
artery can undergo considerable compression in arms
that were hyperextended into a throwing position
 reported at least a 20 mm Hg increase in arterial blood
pressure in athletes and nonathletes when the arm was
placed in that position

12. Differential Diagnosis:

14. Physical Examination:
 Gilliatt-Sumner hand, a characteristic finding of
neurogenic TOS, is described as atrophy of the
abductor pollicis brevis and, to a lesser degree, the
hypothenar musculature and the interossei
 blood pressure difference of 20 mm Hg between the
upper extremities is a significant but rare finding of
vascular TOS
 upper extremity and chest wall may be congested and
edematous with prominent superficial veins in venous
TOS
 In arterial TOS, the upper extremity may appear pale

15.  Distal skin changes, ulcerations, and signs of
microembolic events are rare findings.
 Palpation of the supraclavicular region may reveal
tender
 pain with movements of the neck, shoulder, and
upper limb
WRIGHT TEST:
 decrease in the radial pulse with the arm in
hyperabduction and external rotation, with the head
turned in the opposite direction
 With this maneuver, the radial pulse dampens or
obliterates in up to 7% of the normal population

16. ADSON TEST :
 bringing the arm into extension turning the head toward
the affected side, and taking a deep breath
ROOS TEST:
 the patient places both arms in the 90 abducted
position with the elbows flexed to 90
 The hands are then opened and closed for a 3-minute
period
 Normal persons may have minor discomfort due to
muscular fatigue,
 but patients with TOS have more dramatic symptoms
that replicate their usual discomfort such that they may
not be able to complete the test

17. WRIGHT TEST: ADSON TEST:

18. ROOS TEST:

19. Conservative Management:
STAGE 1:
Focus on patient education, pain control, range of
motion, nerve gliding techniques, strengthening and
stretching
 patients who sleep with the arms in an overhead,
abducted position should get some information about
their sleeping posture to avoid waking up at night
 These patients should sleep on their uninvolved side
or in supine, potentially by pinning down the sleeves
 Encouraging diaphragmatic breathing

20. Scapula Settings and Control-
 important to establishing normal scapula muscle
recruitment and control in the resting position
 progressed to maintaining scapula control while both
motion and load are applied
 programme begins in lower ranges of abduction
 progressed to abduction and flexion range with higher
ranges of elevation

21. STAGE 2:
Massage
Strengthening of the levator scapulae,
sternocleidomastoid and upper trapezius
Stretching of the pectoralis, lower trapezius and scalene
muscles
Postural correction exercises
Relaxation of shortened muscles
Aerobic exercises in a daily home exercise program

22. Exercises:

23. First Rib Mobilization:
 Patient seated
 Thin sheet strap positioned around first rib. Pull strap
towards opposite hip
 Neck retracted, contralateral lateral flexion, and
ipsilateral rotation
 Ipsilateral head rotation emphasizes scalene stretch.
Contralateral rotation emphasizes rib mobilization
Posterior Glenohumeral Glide with Arm Flexion:
 Patient supine
 Mobilizing hand contacts proximal humerus avoiding
corocoid process. Force is directed posterolaterally
(direction of thumb)

24. First Rib mobilization: Posterior GH glide:

25. Anterior Glenohumeral Glide with Arm Scaption:
 Patient prone
 Mobilizing hand contacts proximal humerus avoiding
acromion process
 Force is anteromedially
Inferior Glenohumeral Glide:
 Patient prone
 Stabilizing hand holds proximal humerus
 Mobilizing hand contacts axillary border of scapula
 Mobilize scapula in craniomedial direction along
ribcage

26. Inferior GH Glide: Anterior GH Glide:

27. Article 1:
Acute effects of manual therapy on respiratory parameters
in thoracic outlet syndrome
 Researchers: Melda Sağlam et al.
 Journal: Turkish Journal of Thoracic and Cardiovascular Surgery
2019
 Sample size: 10 subjects
 Stretching of scalene, upper trapezius, sternocleidomastoid,
rectus abdominis, hip flexor muscles
 mobilization of first rib, cervical and thoracic spine,
sacroiliac joints and thorax were applied as manual therapy
program
 Conclusion: A 30-minute single manual therapy session
improved inspiratory muscle strength and respiratory
muscle endurance but not pulmonary function and
expiratory muscle strength in patients with thoracic outlet
syndrome

28. Article 2:
Comparison between Steroid Injection and Stretching
Exercise on the Scalene of Patients with Upper Extremity
Paresthesia: Randomized Cross-Over Study
 Reseachers: Sang Chul Lee et al.
 Journal: Yonsei Medical Journal(South Korea) 2016, March
 Sample Size: Twenty patients in two groups
 Duration: 2 weeks
Conclusion:
 Ultrasound-guided steroid injection or stretching exercise of
scalene muscles led to reduced upper extremity paresthesia
 although injection treatment resulted in more improvements

29. Reference:
 Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr: Thoracic outlet
syndrome: A controversial clinical condition. Part 1: Anatomy, and clinical
examination/diagnosis. J Man Manip Ther 2010;18(2):74-83.
 Sanders RJ, Hammond SL: Management of cervical ribs and anomalous first ribs causing
neurogenic thoracic outlet syndrome. J Vasc Surg 2002;36(1):51-56.
 Atasoy E: Thoracic outlet syndrome: Anatomy. Hand Clin 2004;20(1):7-14, v.
 SandersRJ,HammondSL:Venousthoracic outlet syndrome. Hand Clin 2004;20(1): 113-118,
viii.
 Marine L, Valdes F, Mertens R, Kramer A, Bergoeing M, Urbina J: Arterial thoracic outlet
syndrome: A 32year experience. Ann Vasc Surg 2013;27 (8):1007-1013
 L.A. Watson, T. Pizzari,, S. Balster:Thoracic outlet syndrome part 1: Clinical
manifestations, differentiation and treatment pathways. L.A. Watson et al. / Manual
Therapy 14 (2009) 586–595
 Huang JH, Zager EL: Thoracic outlet syndrome. Neurosurgery 2004;55(4): 897-902,
discussion 902-903.
 Gilliatt RW, Le Quesne PM, Logue V, Sumner AJ: Wasting of the hand associated with a
cervical rib or band. J Neurol Neurosurg Psychiatry 1970;33 (5):615-624.
 Gergoudis R, Barnes RW: Thoracic outlet arterial compression: Prevalence in normal
persons. Angiology 1980;31(8): 538-541.

30.  Klaassen z, Serenson E, Tubbs RS, et al: Thoracic outlet syndrome: A
neurological and vascular disorder. Clin Anat 2014;27 (5):724-732.
 Crosby C.A. et al., Conservative treatment for thoracic outlet
syndrome., Hand Clinics, 2004, Volume 20(1): 43-9
 Hooper T, Denton J, McGalliard M, Brismée J, Sizer P. Thoracic outlet
syndrome: a controversial clinical condition. Part 2: non-surgical and
surgical management. Journal of Manual; Manipulative Therapy. June
2010;18(3):132-138
 Vanti C. et al., Conservative treatment of thoracic outlet syndrome A
review of the literature, Europa Medicophysica, 2006, Volume 42
 Nicholas A. Levine and Brandon R. Rigby:Thoracic Outlet Syndrome:
Biomechanical and Exercise Considerations. Healthcare 2018, 6, 68
 Tüzün Fırat, Sağlam, Naciye Vardar Yağlı, Yasin Tunç, Ebru Çalık
Kütükçü, Kıvanç Delioğlu et al.: Acute effects of manual therapy on
respiratory parameters in thoracic outlet syndrome. Turkish Journal of
Thoracic and Cardiovascular Surgery 2019;27(1):101-106
 Yong Wook Kim, Seo Yeon Yoon, Yongbum Park, Won Hyuk Chang,
and Sang Chul Lee:Comparison between Steroid Injection and
Stretching Exercise on the Scalene of Patients with Upper Extremity
Paresthesia: Randomized Cross-Over Study. Yonsei Med J 2016
Mar;57(2):490-495