Thoracic outlet syndrome is caused by compression of the neurovascular structures in the thoracic outlet. It has three main types based on the structure compressed: neurological, arterial, or venous. Clinical tests like Adson's test and Roos test are used to diagnose the condition. Physical therapy focuses on patient education, pain management, range of motion exercises, nerve gliding techniques, and strengthening to decrease symptoms by addressing tight muscles and improving posture. The goal is to restore motion and provide more space in the thoracic outlet to prevent neurovascular compression.

1. THORACIC OUTLET SYNDROME
PRESENTED BY: DR. ZUNAIRA AHMAD

2. DEFINITION
Thoracic outlet syndrome
(TOS)- a collection of
symptoms brought about by
abnormal compression of
the neurovascular bundle
by bony, ligamentous or
muscular obstacles.
It is NOT an actual diagnosis according to
ICD (International Classification of Diseases).
It is symptom complex.
To detect exclude other pathologies

3. ANATOMY
Interscelene triangle/ Posterior
Scalene port
Costoclavicular Space Sub coracoid Space
Between
Posterior $ Middle
Between
Clavicle and 1st rib
Between
Pectoralis minor tendon
and coracoid process
Contents
• Brachial plexus
• Subclavian artery
Contents
• Subclavian vein
Contents
• Brachial plexus
• Subclavian vein
• Subclavian artery

4. TYPES
Neurological TOS Vascular TOS
Arterial TOS Venous TOS
Compression of Brachial plexus at,
• Posterior scelene port
• subcoracoid space
Compression of subclavian
artery at,
• Posterior scelene port
• subcoracoid space
Compression of subclavian vein
at,
• Costoclavicular space
• subcoracoid space
Young adult with vigorous
arm activity
Younger men with vigorous arm
activity
Signs and symptoms
 Hx of neck trauma
 Pain, paresthesia, numbness, and/or
weakness
 Occipital headaches
 S/s present-day and/or night
 Loss of fine motor skills
 Cold intolerance (possible Raynaud's
phenomenon)
 Objective weakness
 Compressors*: s/s day>night
Signs and symptoms
 Pain
 Fatigue
 Claudication
 Pallor
 Cold intolerance
 Paresthesias
 S/s usually appear
spontaneously
Signs and symptoms
 Cyanosis
 Feeling of heaviness
 Paresthesia in fingers and
hand (result of oedema)
 Oedema of the arm
 Cyanosis
 Venous distension

5. Elevated Arm Stress/
Roos test
Adson’s Test Wright’s Test /
hyperabduction test
Morley / Supraclavicular
Pressure
90° abduction and the
therapist puts downwards
pressure on the scapula
the patient opens and
closes the fingers.
elevate the chin toward
the affected side for 1 min
+ve when radial pulse
diminishes
Vascular compressed by
the scalene muscle or
cervical rib
artery is compressed by
the pectoralis minor
muscle or coracoid
process
squeezes the fingers and
thumb together for 30
seconds.
Addresses compromise to
brachial plexus through
scalene triangles.
CLINICAL TESTS

6. CAUSES
• CERVICAL RIB
• LONG C7 TRANSVERSE PROCESS
• ANOMALOUS INSERTION OF SCALENE MUSCLES
• SCALENE MUSCLE HYPERTROPHY
• SCALENEUS MINIMUS
• ABNORMAL BANDS, LIGAMENTS
• FRACTURE CLAVICLE/ 1ST RIB
• EXOSTOSIS
• TUMOURS
• BRACHIAL PLEXUS TRAUMA / DISEASES

7. Cervical radicular syndrome
Symptoms are mostly limited to one
spinal root
Peripheral nerve entrapment
Symptoms are mostly limited to one
nerve
TOS/ brachial plexus compression
Symptoms are more widespread
Upper brachial
plexus (C5-C7)
Lower brachial
plexus (C8-T1)
Often
compressed by
scalene triangle
Often
compressed by
cervical rib or
elongated C7
transverse
process
PAIN
• Localized
• Follow peripheral nerve or
dermatomal pattern
• Relieved by arm elevation
PAIN
• Localized
• Follow peripheral nerve pattern
• Relieved by arm elevation
PAIN
• Poorly localized
• Does not follow peripheral nerve
or dermatomal pattern
• Worsened by prolonged arm
elevation
Motor Median nerve with CTS: 1st two
lumbricals, abductor pollicis brevis
MOTOR
Weakness and
Hand Weakness,
atrophy of
DIFFERENTIAL DIAGNOSES

9. PHYSICAL THERAPY MANAGEMENT
• Focuses mainly on patient education, pain control, range of motion, nerve gliding techniques,
strengthening and stretching.
• Stage 1: The aim of the initial stage is to decrease the patient’s symptoms.
• patient education
• bad postures education
• patients should sleep on their uninvolved side or supine, potentially by pinning down the sleeves.
• Pain management
• Cyriax Release Maneuver
• Elbows flexed to 90°
• Towels create a passive shoulder girdle elevation
• Supported spine and the head in neutral
• The position is held until peripheral symptoms are produced. The patient is encouraged to allow symptoms to occur
as long as can be tolerated for up to 30 minutes, observing for a symptom decrescendo as time passes.
• Control edema
• Start lower grade AROMs

10. STAGE 2:
• The goal of this stage is to directly address the tissues that create structural limitations of motion and compression.
• Massage
• Exercises:
1. Shoulder exercises to restore the range of motion and so provide more space for the neurovascular structures.
Exercise: Lift your shoulders backwards and up, flex your upper thoracic spine and move the shoulders forward and down. Then
straighten the back and repeat 5 to 10 times.
2. ROM of the upper cervical spine
Exercise: Lower your chin 5 to 10 times against your chest, while you are standing with the back of your head against a wall.
The effectiveness of this exercise can be enlarged by pressing the head down by hands.
3. Activation of the scalene muscles is the most important exercises. These exercises help to normalize the function of the thoracic
aperture as well as all the malfunctions of the first rib. Exercises are Anterior scalene (Press your forehead 5 times against the
palm of your hand for a duration of 5 seconds, without creating any movement), Middle scalene (Press your head sidewards
against your palm), Posterior scalene (Press your head backwards against your palm
4. Stretching exercises of the pectoralis, lower trapezius and scalene muscles (These muscles close the thoracic outlet)
• Postural correction exercises
• Relaxation of shortened muscles
• Aerobic exercises in a daily home exercise program
• First Rib Mobilization