Thoracic Outlet Syndrome Quiz

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Questions and Answers

What percentage of thoracic outlet syndrome (TOS) cases is related to vascular compression?

10-15%

20-25%

3-5% (correct)

1-2%

Which of the following is the most commonly compressed neural structure in TOS?

Lowest trunk of the brachial plexus (correct)

Subclavian nerve

Thoracic nerves

Cervical nerves

What factor contributes to a higher prevalence of TOS in women compared to men?

Higher physical activity levels

Greater muscle mass

Narrowed thoracic outlet (correct)

Older mean age

Which type of thoracic outlet syndrome is characterized by true neurological deficits?

True Neurological TOS (tTOS) Signup and view all the answers

What anatomical variation is responsible for most neural compression in TOS?

Cervical ribs Signup and view all the answers

What is the mean age range of individuals affected by thoracic outlet syndrome?

30s to 40s Signup and view all the answers

Which structure is least likely to be affected in cases of thoracic outlet syndrome?

Radial nerve Signup and view all the answers

Which of the following descriptions applies to Symptomatic TOS (sTOS)?

Has no detectable objective abnormalities Signup and view all the answers

What posture is commonly exhibited by individuals with thoracic outlet syndrome (TOS)?

Flexed head, depressed and anteriorly shifted shoulder Signup and view all the answers

Which muscle group is primarily affected when the scalenes tighten in relation to thoracic outlet syndrome?

Scalenes Signup and view all the answers

What is a consequence of poor diaphragmatic usage according to the provided content?

Muscle hypertrophy in the scalenes Signup and view all the answers

What effect does a tight pectoralis minor muscle have on shoulder mechanics?

Tilts the scapula forward and promotes adduction Signup and view all the answers

Which of the following statements is NOT true regarding scapular stability in the context of TOS?

Weakness in scapular muscles enhances shoulder mobility Signup and view all the answers

What is the role of the sternocleidomastoid in relation to TOS?

Causes shortening and misalignment of neck posture Signup and view all the answers

Which condition can further constrict the costoclavicular space in individuals with TOS?

Presence of a supernumerary cervical rib Signup and view all the answers

What type of work activity is most likely to lead to a decrease in the costoclavicular space?

Overhead reaching and repeated loading Signup and view all the answers

What is the recommended range of active knee flexion by the 7th postoperative day?

50-70 degrees Signup and view all the answers

What is the initial flexion range controlled by the CPM machine during the first 24 hours post-surgery?

40 degrees Signup and view all the answers

Which of the following is a correct statement regarding the disadvantages of using a CPM machine?

It can lead to discomfort in patients. Signup and view all the answers

What should be done if a patient has not reached the desired knee flexion by day 7?

Start CPM therapy for maximum flexion. Signup and view all the answers

Which intervention is indicated if there is an extensor lag during CPM usage?

Stop progression of passive flexion. Signup and view all the answers

What is the expected knee flexion attainment by day 14 with the use of CPM?

80-90 degrees Signup and view all the answers

What is indicated when a CPM machine is not available and extensor lag occurs?

Use manipulation under anaesthesia. Signup and view all the answers

When can unsupported weight bearing typically begin for a patient post-surgery?

Postoperative day 2 with splint Signup and view all the answers

What is the primary purpose of knee arthroplasty?

To relieve pain and provide motion Signup and view all the answers

Which of the following is NOT considered a contraindication for knee arthroplasty?

Rheumatoid arthritis Signup and view all the answers

What is the primary focus of a bi-compartmental knee replacement?

Replacing surfaces of both medial and lateral compartments Signup and view all the answers

What type of surgical approach is suggested for larger-chested women to relieve thoracic outlet syndrome symptoms?

Breast-reduction surgery Signup and view all the answers

Which exercise should be practiced during the preoperative rehabilitation phase?

Isometric quadriceps exercises Signup and view all the answers

What does postoperative rehabilitation after knee arthroplasty focus on in the initial stages?

Shoulder and cervical range of motion exercises Signup and view all the answers

Which type of fixation is NOT a classification used for knee arthroplasty?

Adaptive fixation Signup and view all the answers

What action should be taken on the first day post-operation to minimize pressure sores?

Varied position changes every hour Signup and view all the answers

What is the rationale for performing quadriceps sets hourly during the early postoperative stage?

To reduce joint effusion and muscle inhibition Signup and view all the answers

How long should overhead activities and lifting be avoided after knee arthroplasty?

2–4 weeks Signup and view all the answers

Which symptoms are specifically associated with upper plexus involvement in neurogenic thoracic outlet syndrome?

Pain that radiates to the ear and face Signup and view all the answers

What determines the initial position of the knee in patients who do not use a CPM machine post-surgery?

Extended for 4 days with a pressure bandage Signup and view all the answers

Which of these classifications pertains to knee arthroplasty based on the portion of the knee being replaced?

Uni-, bi-, and tri-compartmental Signup and view all the answers

What distinguishes compressors from releasers in thoracic outlet syndrome?

Compressors exhibit symptoms throughout the day Signup and view all the answers

What is a primary symptom that may be alleviated by using the Cyriax release maneuver for thoracic outlet syndrome?

Paresthesias Signup and view all the answers

Which activity is allowed from Day 2 after surgery if there is no CPM machine used?

Assisted weight bearing Signup and view all the answers

What are ankle pumps intended to achieve during the early postoperative stage?

Promote circulation and minimize DVT Signup and view all the answers

Which symptom is commonly observed in patients experiencing venous thoracic outlet syndrome?

Cyanosis of the hand or fingers Signup and view all the answers

What does a uni-compartmental knee replacement aim to replace?

Opposing surfaces of either the medial or lateral compartment Signup and view all the answers

What is a key symptom of arterial thoracic outlet syndrome?

Claudication pain in arms during activity Signup and view all the answers

Which symptom is indicative of true thoracic outlet syndrome?

Loss of fine motor skills Signup and view all the answers

In which situation would a patient likely be classified as experiencing releasers symptoms?

Symptoms are primarily experienced at night Signup and view all the answers

Which of the following signs is indicative of lower plexus involvement in thoracic outlet syndrome?

Pain radiating to the anterior shoulder Signup and view all the answers

What is a distinguishing feature of disputed neurogenic thoracic outlet syndrome?

Nocturnal symptoms are experienced more than daytime symptoms Signup and view all the answers

Study Notes

Achilles Tendinopathy/Tendinosis/Tendinopathy

Refers to a combination of pathological changes affecting the Achilles tendon, usually due to overuse and chronic stress.
Can occur in athletes and non-athletes.
May or may not be associated with an Achilles tendon tear.
Lack of flexibility or a stiff Achilles tendon increases the risk of injury.
The thickest and strongest tendon in the body.
Originates from the gastrocnemius and soleus muscles, inserting on the calcaneal tuberosity.
Approximately 15 cm (6 inches) long.
Experiences stress of 3.9 times body weight during walking and 7.7 times body weight during running.
Surrounded by a paratenon (connective tissue sheath) instead of a synovial sheath.
Paratenon provides the major blood supply to the tendon.
Blood supply comes distally from intraosseous vessels (calcaneus) and proximally from intramuscular branches.
A relative avascular zone exists 2-6 cm from the calcaneal insertion, making it vulnerable to degeneration and injury.
Blood supply is evident at the muscle-tendon junction and tendon-bone insertion.
Vascular density is greatest proximally and least in the midportion of the tendon.
Tendon injuries are commonly associated with repetitive impact loading from running and jumping.
Either the tendon or paratenon (or both) can become inflamed, resulting in tendonitis or peritendinitis.
Tendinopathy is a common overuse injury caused by repetitive energy storage and release with excessive compression. This can lead to a sudden injury or a rupture.
Commonly called Achilles tendonitis, but more accurately described as tendinosis (not inflammation).
Classified into insertional (within 2 cm of insertion) and mid-substance/noninsertional (2-6 cm proximal to insertion).

Causes of Achilles Tendonitis

Overuse injury with forces within the physiological range, but repeated with poor recovery time, causing fatigue and increasing susceptibility to micro-tearing.
Sudden loading of excessive force, especially with eccentric motion, causing damage.
Insufficient flexibility in the gastrocnemius and soleus muscles, increasing strain on the tendon and causing micro-tears.
Muscle weakness in the gastrocnemius and soleus which results in micro-tears and inflammation of the Achilles tendon.
Joint restrictions (e.g., pes cavus) in the talocrural or subtalar joints decrease shock absorption and adaptability to uneven terrain.
Excessive pronation leads to internal tibial rotation, drawing the Achilles tendon medially (whipping action) and contributing to overuse degeneration and inflammation or small tears, particularly in the medial aspect.
Systemic diseases such as diabetes, lupus, and gout are associated with tendon weakness.
Corticosteroid injections can cause tendon rupture and are controversial.
Poor footwear (too small, worn-out, poor heel counter) reduces rear foot stability and shock absorption.
Running on unyielding or uneven surfaces.

Physical Examination and Findings

Morning pain is a hallmark symptom.
Diffuse pain in or around the back of the ankle and heel, aggravated by activity (especially uphill running or stair climbing).
Pain is relieved somewhat by wearing higher-heeled shoes or boots.
Recent increase in activity levels or changes in footwear is often reported by patients.
Observable, palpable edema and thickening of the Achilles tendon (A-P and M-L).
Painful and prominent lumps or nodules within the tendon.
Crepitus during plantar and dorsiflexion, detected through arc sign.

Diagnosis

Diagnosis uses history, symptom behavior, clinical tests, ultrasound (for tendons, water content, collagen integrity and bursal swelling), X-rays (for bone changes, calcification), and MRI (for surgery planning).
X-rays visualize calcification in the tendon (insertional) or midportion (severe noninsertional) tendinopathy.

Differential Diagnosis

Plantar fasciitis
Calcaneal fracture stress
Heel pad syndrome
Haglund deformity
Sever's disease
Posterior Ankle Impingement
Medial Tendinopathy
Retrocalcaneal Bursitis
Sural Nerve
Lumbar Radiculopathy
Ankle OA
Deep vein thrombosis
Partial Achilles Tendon Rupture

Treatment and Management

Aims for optimizing foot biomechanics, controlling symptoms (pain, swelling, inflammation), protecting the inflamed tendon, and enhancing tendon healing and muscle activity balance.
Conservative management:
- Medication (NSAIDs)
- Physical therapy (RICE, cross-training, and specific exercises)
- Corticosteroid injections (use cautiously, risk of rupture)
- Platelet-Rich Plasma (PRP) injections
Surgical management is considered if conservative approaches fail.
Physical therapy includes:
- Implementing RICE (Rest, Ice, Compression, Elevation)
- Orthotics (heel lifts, specialized braces)
- Taping
- Gentle stretching of tight gastrocnemius/soleus complex.
- Isometric-loaded exercises (e.g., heel raises) to strengthen tendons, progressing to more challenging exercises with weight.
- Cross-training on opposite ankle
- Specific positions to reduce pressure on the affected area
- Physiotherapy treatments (e.g soft tissue mobilization)
The physician may recommend using a walking boot for a short period in case of severe pain.

Thoracic Outlet Syndrome (TOS)

Compression of neurovascular structures (nerves, blood vessels) exiting the thoracic outlet.
Outlet is bordered by the first rib, clavicle, upper border of the scapula, and sternum.
Marked by the anterior scalene, middle scalene, and subclavian vasculature/neurovascular bundle.
The thoracic outlet is both confined and dynamic.
Symptoms are often controversial and depend on whether the nerves, blood vessels, or both are compressed.
- Typical findings include:
  - Numbness or tingling in the arm or fingers.
  - Pain or aches in neck, shoulder, arm, or hand.
  - Arm fatigue with activity.
  - Weakening grip.
Causes of TOS often are anatomical defects:
- Extra rib located above first rib.
- Cervical ribs (0.5-0.6% pop., 50-80% bilateral)
- Fibromuscular bands connected to cervical ribs (most neural compression cause).
- Poor posture, causing shortening of the sternocleidomastoid muscle, thereby creating a shortened scalene and pectoralis muscle grouping, which leads to improper head-neck alignment.
- Injuries or repetitive activities (e.g., typing, heavy lifting).
Classifications:
- Vascular (vTOS):
  - Color changes in hands, or fingers (cyanosis)
  - Hand or arm pain and swelling
  - Pulsating lump near collarbone.
  - Cold hands or fingers.
  - Hand and arm pain (claudication pain)
- Neurological (nTOS): (includes true and disputed types of nTOS)
Diagnostic procedures include electrophysiological studies and imaging.
Treatment involves physical therapy (mobilization, stretching), activity modification, and potentially surgery if conservative measures are unsuccessful.

Rehabilitation After Knee Arthroplasty

. Preoperative rehab includes measuring pain, swelling, functional ability, range of motion, and muscle strength. Patients are trained to use assistive devices like walkers or crutches, along with practicing isometric exercises, like quadriceps.

. Postoperative rehab includes deep breathing, ankle pumps, upper extremity exercises(e.g., moving the patella up and down), frequent quadriceps exercises, and attempts at SLR (straight leg raises) after the first two days if not contraindicated.

. Two main forms of management are used: No CPM or CPM. No CPM includes maintaining the knee in an extended position, using pressure bandages, and splints. CPM uses a continuous passive motion machine to actively exercise the knee post-surgery.

. The types of exercises used to rehabilitate the knee after surgery include isometric, active, and resisted exercises and are tailored to each patient's needs and determined by the surgeon.

. The rehabilitation process after knee arthroplasty varies based on the specific type of prosthesis (cemented or cemented-less, and the specific situation of each patient.

. Proprioception training, walking/stair climbing, and avoidance of twisting, jumping and running are crucial to consider in patient rehabilitation programs.

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Description

Test your knowledge about thoracic outlet syndrome (TOS) with our quiz! Understand the vascular and neural components, common symptoms, and anatomical variations associated with TOS. This quiz will help you grasp the critical aspects of TOS more effectively.