Thoracic Outlet Syndrome
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- Belinda Carroll
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1 Thoracic Outlet Syndrome Part 1: The Scalene Triangle TOS: Vascular Symptom Presentation Venous persistent/intermittent edema heaviness and fatigue deep pain in neck/shoulder increased pain at night warm cyanotic hand Arterial ischemic pain: exercise induced numbness/coldness of hand lower blood pressure pallor/skin color changes auscultated bruit (subclavian stenosis) TOS: Neurological Symptom Presentation Paraesthesia typically along the C8-T1 distribution. Atrophy of the ulnar intrinsic muscles. Weakness and incoordination. Pain generalized in the arm and hand. Tingling and numbness in the neck, shoulder, arm and hand. 1
2 TOS: Symptom Presentations Classically taught to be at low trunk of the BP as it crosses over the first rib and under the clavicle. Second syndrome is the upper trunk presentation from C5, 6 and can extended to C7/middle trunk involvement. 2
3 Injury Treatment Resolution Healing/Repair Normal Biological response? Assess response Biopsychosocial Model for Treatment Biopsychosocial Pain Model Distress Illness Behavior Beliefs Social Demands Pain Anatomic Review Muscle Anatomy Scalene Anterior Scalene Middle Scalene Posterior Origins/Insertions Anterior TP 3-6 to first rib. Posterior TP 2-7 to first rib. Posterior TP 4-6 to second rib 3
4 original image File:Musculi coli base.svg Olek Remesz (wiki-pl: Orem, commons: Orem) Modified by user:madhero Cadaver View Source Author Own work Anatomist90 4
5 Scalene Triangle and Brachial Plexus Own work Author Anatomist90 Emerging Brachial Plexus Own work Author Anatomist90 Scalene Muscles: Actions Bilateral Action: Forward flexion of the head. Unilateral action: Laterally flex the cervical spine with the ribs fixed. Elevates the first and second ribs during respiration. With stabilization: Ipsilateral rotation of the upper cervical spine. Contralateral rotation of the lower cervical spine. 5
6 Scalenus Anterior Isolated action is forward neck flexion First rib elevation during inspiration Scalenus Medius Action is lateral neck flexion First rib elevation during inspiration Scalenus Posterior Action is lateral neck flexion Second rib elevation during inspiration 6
7 Posterior View First Rib Structure Lateral View of Rib Cage 7
8 First Rib Insertion Points Sternothyroid: Sternohyoid: Omohyoid: Anterior Neck Muscles Depresses the hyoid bone and the larynx Anterior Neck Anatomy & Physiology, Connexions Web site. OpenStax College 24 8
9 25 26 Brachial Plexus Exiting ST 9
10 28 Soft Tissue Compression Muscles: Scalene. Pec. Minor. Subclavius. Omohyoid. 10
11 Pathoanatomical Structures Bone. Cervical rib. Clavicle. Abnormal transverse process. Cervical Rib Symptom Presentation Neurological: Pain. Paraesthesia. Motor weakness. Vasomotor changes. Raynaud s phenomenon. 11
12 Differential Diagnosis Cervical pathology. CTS. Cubital tunnel. Shoulder pathology. CRPS. Radial nerve compression. Space occupying lesion. Cervical Ribs Lung CA. Spinal cord tumors. Cervical Spine Screening Check cervical AROM Flexion/extension Rotation Side bending Provocative testing as indicated: Spurling s Maneuver. Cervical Spine: Active Movements 12
13 Cervical Spine Screening Cervical Spine: Combined Movements Objective Evaluation: Structural Postural assessment. Shoulder contours and heights. Scapula winging. Clavicluar abnormalities. 13
14 Adson s Test Obliteration of the radial pulse with head turn to the ipsilateral side. Should also be assessed to the contralateral side Predictive value for vascular TOS is minimal. Used as a screening assessment for neurogenic symptom provocation. 14
15 43 Costoclavicular Test Supraclavicular Fossa Test 45 15
16 Scalene Assessment with Rib Stabilization Double Crush Syndrome Can be multiple compression of one nerve. Can be multiple nerves in different sites. 16
17 Treatment Planning What makes sense? What are your observations? What is the overall goal? Emphasis on patient education and participation. Focus on one problem at a time. Treatment Interventions First rib mobilization. Trigger point release Self mobilization/stretching programs. Ergonomic/postural assessment and correction. Inspiration Training 17
18 First rib mobilization Inferior glide with inspiration First rib mobilization A/P mobilizations with movement Scalene Referral Patterns 18
19 Scalene Stretching Scalene muscles are properly mobilized with the head in multiple positions Median Nerve Gliding Ergonomic Considerations: Office Workstation Issues 19
20 Proper Work Station 20
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