Thoracic outlet syndrome is a condition that involves compression of the nerves or blood vessels that pass through the base of the neck. This can lead to disabling pain in the neck and shoulder, as well as pain, numbness, tingling and weakness in the hands and fingers.Thoracic outlet syndrome (TOS) is a term used to describe a group of disorders that occur when there is compression, injury, or irritation of the nerves and/or blood vessels (arteries and veins) in the lower neck and upper chest area. Thoracic outlet syndrome is named for the space (the thoracic outlet) between your lower neck and upper chest where this grouping of nerves and blood vessels is found.
Who is affected by thoracic outlet syndrome?
Thoracic outlet syndrome affects people of all ages and gender. The condition is common among athletes who participate in sports that require repetitive motions of the arm and shoulder, such as baseball, swimming, volleyball, and other sports.
Neurogenic TOS is the most common form of the disorder (95 percent of people with TOS have this form of the disorder) and generally affects middle-aged women.
Recent studies have shown that, in general, TOS is more common in women than men, particularly among those with poor muscular development, poor posture or both.
What are the symptoms?
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The signs and symptoms of TOS include neck, shoulder, and arm pain, numbness or impaired circulation to the affected areas.
The pain of TOS is sometimes confused with the pain of angina (chest pain due to an inadequate supply of oxygen to the heart muscle), but the two conditions can be distinguished because the pain of thoracic outlet syndrome does not occur or increase when walking, while the pain of angina usually does. Additionally, the pain of TOS typically increases when raising the affected arm, which does not occur with angina.
Signs and symptoms of TOS help determine the type of disorder a patient has. Thoracic outlet syndrome disorders differ, depending on the part(s) of the body they affect. Thoracic outlet syndrome most commonly affects the nerves, but the condition can also affect the veins and arteries (least common type). In all types of TOS, the thoracic outlet space is narrowed, and there is scar formation around the structures.
Types of thoracic outlet syndrome disorders and related symptoms
Neurogenic thoracic outlet syndrome: This condition is related to abnormalities of bony and soft tissue in the lower neck region (which may include the cervical rib area) that compress and irritate the nerves of the brachial plexus, the complex of nerves that supply motor (movement) and sensory (feeling) function to the arm and hand. Symptoms include weakness or numbness of the hand; decreased size of hand muscles, which usually occurs on one side of the body; and/or pain, tingling, prickling, numbness and weakness of the neck, chest, and arms.
Venous thoracic outlet syndrome
2. WHAT IS THORACIC OUTLET SYNDROME?
• The thoracic outlet is the space between your collarbone (clavicle)
and your first rib. This narrow passageway is crowded with blood
vessels, nerves and muscles. This may cause shoulder and neck
pain and numbness in your fingers.
• The subclavian vein and the subclavian artery are the major
blood vessels which can be affected.
• The Brachial Plexus is the group of nerves which is affected.
• The Anterior scalene, middle scalene and pectoralis minor are the
major muscles which can be affected.
3. BOUNDRIES OF TOS
• Posteriorly – T1 Vertebral body
• Laterally – First rib and costal cartilage
• Anteriorly – Manubrium sterni
4. ANATOMY OF THORACIC OUTLET
INTER SCALENE TRIANGLE
• Inferiorly – First rib
• Anteriorly – Scalenus anterior
• Posteriorly – Scalenus medius
COSTOCLAVICULAR SPACE
• Anterior – Clavicle and the
subclavius muscle
• Post. medial – First rib
• Post. lateral – Superior border of
scapula
5. • The thoracic outlet is
located in the lower part of
the neck, just above and
behind the clavicle. It
extends underneath the
clavicle to the area just in
front of the shoulder.
6. TYPES OF TOS
The Thoracic Outlet Syndrome is of three types, namely :-
1. Neurogenic TOS- 95% of the cases are of neurogenic type of TOS
2. Venous TOS – 3% to 4% of the cases are of venous type of TOS.
3. Arterial TOS- 1% TO 2% of the cases are of arterial type of TOS.
8. SIGN AND SYMPTOMS:
. Scars tissue form around brachial
plexus .
.Pain between neck , face ,and occipital
region or into chest ,shoulder.
.weakness , fatigue , numbness , feeling
heaviness in arm and hand.
. Skin discolour , different temperature
observe.
9. COMPLICATIONS OF TOS
• Permanent arms swelling and pain (if left untreated)
• Ischemic ulcer of the fingers.
• Gangrene
10. DIFFERENTIAL DIAGNOSIS:
• Carpal tunnel syndrome: it is caused by compression of median
nerve. It is more common in household working female.
• Lateral epicondylitis: It is also called as tennis elbow and can be
caused by repetitive wrist and arm motions.
• Medial epicondylitis :It is also called as Golfer’s elbow and can be
caused due to excess or repetitive stress often by forceful wrist and
fingers motion.
11. CAUSES OF TOS:
• Congenital factors -
(a) Abnormalities of insert of scalene muscles.
(b) Fibrous muscles band
(c) Cervicodorsal scoliosis
(d) Extra presence of the first rib
• Acquired factors -
(a) Postural factors
(b) Dropped shoulder
(c) Fracture of clavicle
12. (d ) Fracture of rib
• Muscular causes
(a) Hypertrophy
(b) Decrease tone of muscle
(c) Shortening of the muscles
17. MEDICAL MANAGEMENT OF TOS
• Nonsteroidal anti-inflammatory drugs – It helps to relieves from pain,
decreases inflammation and reduces fever.
• Analgesics
• Antipyretics
• Surgical managements – (a) Transaxillary approach
(b) Supraclavicullar approach
(c) Infraclavicullar approach
(d) Removal of the extra rib
(e) Removal of the fibrous band
18. PHYSIOTHERAPY MANAGEMENT OF TOS
The physiotherapy management of Thoracic Outlet Syndrome is done
in two stages. Both of the stages are described below :-
Stage I – In the first stage of the physiotherapy managements of the
Thoracic Outlet Syndrome, we mainly focus on the controlling of the
movements and breathing of the patient.
(a) Breathing techniques (encourage diaphragmatic breathing)
(b) Controlling humeral head position
(c) Control and recruitment of serratus anterior
19. Stage II – In stage two, we mainly focus on the strengthening of the
muscles and on the postural correction.
(a) Therapeutic massage
(b) Strengthening of the pectoralis major, pectoralis minor,
levator scapulae, upper trapezium
(c) Postural correction – Relaxing of thigh (short) muscles
20. • Apart from this, we also do the reposition and give the mobilization of
C5, C6 and C7 to the patient.
(a) Glides of the glenohumeral joint
(b) Mobilization of the glenohumeral joint
• We also do the tapping be K-tape for relaxation and assisting and
support of the affected area.
