Thoracic Outlet Syndrome What is it?
The term ‘thoracic outlet syndrome’ describes compression of the neurovascular structures as they exit through the thoracic outlet (cervicothoracobrachial region). The thoracic outlet is marked by the anterior scalene muscle anteriorly, the middle scalene posteriorly, and the first rib inferiorly. This condition has emerged as one of the most controversial topics in musculoskeletal medicine and rehabilitation. This controversy extends to almost every aspect of the pathology including the definition, incidence, pathoanatomical contributions, diagnosis, and treatment.
What are its causes?
- Cervical Rib
- Prolonged transverse process
- Anomalous muscles
- Fibrous anomalies (transverse costal, costocostal)
- Abnormalities of the insertion of the scalene muscles
- Fibrous muscular bands
- Exostosis of the first rib
- Cervicodorsal scoliosis
- Congenital uni- or bilateral elevated scapula
- Location of the A. or V. Subclavian in relation to the M. scalene anterior
- Postural factors
- Dropped shoulder condition
- Wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine)
- Heavy duty work
- Clavicle fracture
- Rib fracture
- Hyperextension neck injury, whiplash
- Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long hours)
- Hypertrophy of the scalene muscles
- A decrease of the tonus of the M. trapezius, M. levator scapulae, M.rhomboids
- Shortening of the scalene muscles, M. trapezius, M. levator scapulae, pectoral muscles
How can physiotherapy help treat Thoracic Outlet Syndrome ?
Conservative management should be the first strategy to treat TOS since this seems to be effective at decreasing symptoms, facilitating a return to work and improving function, but yet a few studies have evaluated the optimal exercise programme. Conservative management includes physiotherapy, which focuses mainly on patient education, pain control, range of motion, nerve gliding techniques, strengthening and stretching.
The aim of the initial stage is to decrease the patient’s symptoms. This may be achieved by patient education. The patient’s breathing techniques need to be evaluated as the scalenes and other accessory muscles often compensate to elevate the rib cage during inspiration. Encouraging diaphragmatic breathing will lessen the workload on already overused or tight scalenes and can possibly reduce symptoms. Once the patient has control over his/her symptoms of pain physiotherapist can address the tissues that create structural limitations of mobility and compression.
Considered exercise programme
- Shoulder exercises to restore the range of motion so to provide more space for the neurovascular structures. Exercise: Lift your shoulders backward and up, flex your upper thoracic spine and move the shoulders forward and down.
- 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.
- Activation of the scalene muscles: These exercises help to normalise the function of the thoracic aperture as well as all the malfunctions of the first rib. Exercises: 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 backward against your palm.
- Stretching exercises
- Repositioning/mobilisation of the shoulder girdle and glenohumeral joints: cervicothoracic, sternoclavicular, acromioclavicular, and costotransverse joints
- Glenohumeral mobilisations in end-range elevation with the elbow supported in extension
- Taping: some patients with severe symptoms respond to additional taping, adhesive bandages or braces that elevate or retract the shoulder girdle.
- First Rib Mobilisation: Patient seated. Thin sheet strap positioned around the first rib. Pull strap towards opposite hip. Neck retracted contralateral lateral flexion and ipsilateral rotation. Ipsilateral head rotation emphasises scalene stretch. Contralateral rotation emphasises rib mobilisation
- Posterior Glenohumeral Glide with Arm Flexion: Patient supine. Mobilising hand contacts proximal humerus avoiding the coracoid process. Force is directed posterolaterally (direction of thumb).
- Anterior Glenohumeral Glide with Arm Scaption: Patient prone. Mobilising hand contacts proximal humerus avoiding the acromion process. Force is anteromedially.
- Inferior Glenohumeral Glide: Patient prone. Stabilising hand holds proximal humerus. Mobilising hand contacts axillary border of the scapula. Mobilise scapula in a craniomedial direction along ribcage.