Thoracic Outlet Syndrome Treatment - VCMT PDF

Thoracic Outlet Syndrome Anatomy Compression/entrapment (non-degenerating) of the neurovascular tissues of the brachial plexus. 3 main compression sites ​ Interscalene triangle (anterior-middle scalenes) ​ Clavicle & first rib ​ Coracoid process & pec minor A 4th compression site is...

Thoracic Outlet Syndrome Anatomy Compression/entrapment (non-degenerating) of the neurovascular tissues of the brachial plexus. 3 main compression sites ​ Interscalene triangle (anterior-middle scalenes) ​ Clavicle & first rib ​ Coracoid process & pec minor A 4th compression site is at an anatomical anomaly called a cervical rib. This is an overgrown C7 TvP which resembles a rib that grows from the C7 TvP to Rib 1. The brachial plexus ​ Roots: C5-C8 & T1 ​ Trunks: Superior, Middle, Inferior ​ Divisions: Anterior, Posterior ​ Cords: Lateral (C5-C7 nerve roots), Posterior (C5-T1 nerve roots), Medial (C8-T1 nerve roots) ​ Branches: Musculocutaneous (Lat cord), Axillary (Post cord), Radial (Post cord), Median (Lat & Med cords), Ulnar (Med cord) (& 11 other nerves) Palpation Palpation of the plexus: Palpate the lateral edge of the clavicular head of SCM. Directly next to that is the anterior scalene. Directly next to that is the brachial plexus. Palpation should cause the body to feel discomfort radiating under the clavicle towards the coracoid process and possibly some paresthesia in the hand. Palpation of affected tissue: Assess for low muscle tone of muscles down the entire upper extremity. Exactly which muscles will indicate which cords/roots are affected. Edema in the hand, especially the dorsum, may occur as a result of venous occlusion. VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Pathophysiology (Rattray/Ludwig; p825) Symptoms Nerve: pain (local and referred), sensory loss or changes, motor weakness (subtle) (not flaccidity) Vein: edema (hand, especially dorsum), cyanosis Artery: coldness in extremities, pallor, trophic changes (if severe) ​ Due to its anatomy, the part of the brachial plexus compressed (non-degenerating) in TOS is the medial cord. This stems from roots C8 & T1 and terminates in the ulnar nerve. Therefore, neural symptoms of TOS occur in an ulnar nerve distribution (the great majority of the time (90% of cases). Symptoms do not present in a myotome/dermatome pattern (though they are similar) because compression is occurring at the cord, not the root (even though the cord comes from the root). Subtle weakness & atrophy ​ Wrist flexion and ulnar deviation ​ Adductor pollicis (Froment’s sign)​ ​ ​ Intrinsic hand muscles (lumbricals, PIM, DIM) Sensory ​ Digits 5 & medial half of 4 (both palm and dorsum) ​ Sometimes through the forearm distal to cubital tunnel (under FCU) Onset is usually insidious. Some causes include: Internal compression - cervical rib External compression - crutches Poor posture – hyperkyphosis, scoliosis, etc Systemic disorders – RA, diabetes, hypothyroid Trauma/joint subluxation – whiplash Pregnancy – fluid retention plus postural changes Cervical rib compression Prevalence of cervical rib about 3% Since it attaches close to the plexus, it can put pressure on the tissue Variable symptoms and severity Anterior Scalene Syndrome Related to hypertoned/inflamed scalenes, or TrP in scalenes (a Ddx) Symptoms could be neural or arterial The subclavian vein does not go through the interscalene triangle Venous symptoms therefore strongly suggest compression is not occurring at the interscalene triangle ​ Costoclavicular Syndrome Related to tone/inflammation of subclavius, or TrP in subclavius (a Ddx) Related to depressed shoulders (associated with wearing heavy bags) or chronic respiratory problems Symptoms could be neural, arterial, or venous Costoclavicular syndrome is the compression site most likely to cause venous symptoms such as distal edema VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Pec Minor Syndrome (hyperabduction syndrome) Related to sustained or habitual overhead postures or activities (sleep position, work/labor, violin/flute etc) Overhead (max abduction & ext rot) stretches the neurovascular bundle between the coracoid process and pec minor tendon Symptoms could be neural, arterial, or venous Compression Sensory Sx Venous Sx Arterial Sx Classic MOI Positive Test Scalenii anticus Digit 5 & None Pallor Neck postures Adson’s; and medius Medial 4 Coldness Supine/side Halstead’s / Heaviness lying Travell’s Costoclavicular Digit 5 & Most likely site Pallor Carrying heavy Costoclavicular Medial 4 Cyanosis Coldness stuff on syndrome test; Edema Heaviness shoulders Eden’s Pec minor - Digit 5 & Possible Pallor Overhead Wright’s; coracoid Medial 4 Cyanosis Coldness postures or Edema Heaviness activities Precaution None which are specific to TOS. Rattray/Ludwig p. 834 lists some precautions which are more for systemic conditions/comorbidities. Please read it. Informed consent should be clear that working to alleviate compression will possibly cause recreation of symptoms. This is not a bad thing, nothing is being damaged, but it may be uncomfortable. Discomfort may last 1-2 days. VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome History What is the exact location and nature of the symptoms? ​ Pain, prickling, tingling, numbness? ​ Weakness in wrist or hand? ​ Clumsiness or decreased dexterity? ​ Changes to skin/nails? ​ Changes to colour/temperature of hands? Sleeping position? ​ Elbows flexed (tension on ulnar nerve) ​ Arm overhead (pec minor syndrome) ​ Too many pillows supine (scalenes) ​ Not enough pillows side-lying (scalenes) ADLs ​ Overhead postures or activities ​ *Carrying heavy baggage * or *weight on shoulders* *depressing them* (*meant literally) VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Assessment Adson’s (Rattray p.1071) Halstead’s (Magee 5-116) or Costoclavicular syndrome test Travell’s variation (Rattray (Rattray p. 1072) p.1072) Anterior Scalenes compression Middle Scalenes compression Costoclavicular compression Procedure & Positive: Procedure & Positive: Procedure & Positive: VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Eden’s test (Rattray p. 1072) Wright’s Hyperabduction Scalene Cramp (Rattray p.1066) (Rattray p. 1072) Costoclavicular compression Pec minor compression Scalenes TrP Standing Seated Full ipsilateral rotation Monitor radial pulse Max contraction ipsilateral side flexion and flexion (pull chin into Patient does AROM max depression and retraction hollow above clavicle) (+) is diminished radial pulse (+) is recreation of referral pattern from scalenes TrP Procedure & Positive: Procedure & Positive: Procedure & Positive: VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Pec Minor length test (Rattray p. ULTT 4 (Kisner. P369; Rattray p. Froment’s sign 1079) 1074; Magee p.149) Pec minor shortness C8-T1 nerve roots or ulnar nerve Weakness of adductor pollicis tension) Procedure & Positive: Procedure & Positive: Procedure & Positive: VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Differential TrP Scalenes TrP Subclavius TrP Pec Minor TrP Raynaud’s Peripheral ulnar nerve compression (Ulnar groove/cubital tunnel, Guyon’s canal) Ulnar nerve tension Nerve root compression (C8) Person sleeps with flexed elbow (actually quite common!) VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Treatment Decompress the glitchy bits ​ Scalenes with massage, PIR (see below (MET)), NMT, MFR, lateral translations, PA glides ​ Costoclavicular space with subclavius, superior glides SC joint, anterior glides SC joint, pec major ​ Pec minor with massage, supine stretches or sidelying stretches/inhibition ​ Continue through the distal end of the medial cord ​ Medial intermuscular septum ​ FCU Hypothenar Work on any TrP which may contribute If apical breathing Work on diaphragm and intercostals and diaphragmatic breathing If venous symptoms ​ Elevate, unidirectional stroking, manual lymphatic drainage Home Care Rattray p.839 has some suggestions Hydro and stretches as you would expect Diaphragmatic breathing/breathing reeducation (away from apical) Some nice ideas for education and ADL modifications VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome Scalenes MET from Chaitow It is important not to allow heroic degrees of neck extension during any phase of this treatment. There should be some extension but it should be appropriate to the age and condition of the individual. The whole procedure should be performed bilaterally several times in each of the three positions. VCMT Peripheral Nervous System Treatments. Class 3 - Thoracic Outlet Syndrome