I have read several differing methods of conservative treatment programs for patients with Thoracic Outlet Syndrome. I recognize the importance of stretching, strengthening, diaphragmatic breathing and postural correction, but where do you start and how do you progress these patients?
Joined: December 1, 2004
Well, I have yet to see a case of true thoracic outlet. Is there such a thing? But, I think a differential diagnosis would be in order first, to rule out cervical radiculopathy, carpal tunnel, nerve entrapments at the elbow, etc. If all those are reasonably unremarkable, then I would try to locate any entrapment (with provocation and alleviation) around the clavicle, scalenes and pectoralis minor, checking pulses along the way. After this and the rest of the evaluation (active movements, passive movements, strength, sensation, etc), one should have a pretty good idea of impairments. Classically, these types of patients have forward head posture and abducted/protracted scapulae. I usually start training postural awareness and alignment with Pilates-based exercises using the deep diaphragmatic breathing with AROM (chin tucks, arms circles, shoulder shrugs, etc.) in supine. Sometimes only AAROM is tolerated (supine wand overhead) Deep cervical flexor training, and scapular strengthening (low traps, mid traps, serratus) is ussually helpful. Progression would include adding gravity, resistance, and functional movements to these principles while maintaining alignment. Manually, I would jiggle the 1st rib and clavicle and any cervical segments that seem restricted, do soft tissue work (usually opt for the gentler strain-counterstrain type releases over manual muscle stretching) and possibly some gentle intermittant traction. If specific neurodynamic tests are positive, I would address those as well with nerve gliding or unloading procedures and educate the patient how to address this at home/work. Hope my rambling was useful. Sarah
Joined: February 27, 2005
CKV, like Sarah, I too have yet to see ( in 22 years ) a true thoracic outlet syndrome. Along with a great many other medical diagnoses, This one ought to go into the box along with rotator cuff syndrome , ilio tibial band synd. etc as euphemisms for " I don't know ". Often the oderly conduct of the thoracic spine is overpowered by protective responses leading to dysfunction and pain. It is the nature of the spine to behave in this way as a threat response. The job then is to turn this off. Within my own experience , I find success flows quickly in cases where thoracic and cervical joionts have become irritated and had given rise to referred events, to simply mobilise those joints till protective behaviour ceases. very straightforward. Normal neural/muscular behaviour and comfort naturally and immediately follows and is lasting provided normal spinal movements have been restored. Continuous Mobilisation is the method I use . Cheers
Joined: February 14, 2003
From: Madison WI USA
While I do agree with the fact that there are many pseudosyndromes, TOS does exist. It is quite rare, but when the radial pulse shuts off with deep inspiration, and overhead use of the UEs makes the UE go numb and turn white, this is objective vascular TOS. However, this is often structural, and I dont think we can acutally mobilize people out of this, as I dont think the cervical rib mobilization actually helps much in these cases. It should be confirmed by doppler US tests. I completely agree with the idea that the UE sx are often originating in the C spine, not the outlet, but not in all cases.
Joined: May 9, 2004
From: West Palm Beach
I was fortunate or unfortunate enough to work next door to a physiatry pain management group for a couple of years. They were non invasive (trigger pt injections were the most invasive they got) and were the only place around for about a 35 mile radius. Being in an area ripe with high tech jobs, AOL, worldcom, etc..we had lots of people who essentially had RSI of the upper back, neck and arms, but I'd definitely say I saw a LOT of TOS patients. I would basically say I could provoke most of the symptoms with prolonged arm outstetched infront or a roo's type test or supine with arm abducted to like 120 and hanging off the plinth towards the floor. I'd get marked change or loss of pulse, tingling, numbness reproduced. And would usually find neural tension, forward head, rounded shoulders weak postural stabilizers, and the whole sompendium of things that go along with a RSI of the upper extremity and TOS. Funny enough, since I have moved to florida (4 years ago) I have not seen one case of this. I think geographically, your typical cases change. Down here people are much more active, our commute times are a lot less, people work to live rather than live to work like the dc metro area. Since people are out and about playing sports year round and fishing and boating etc, i see a lot more acute trauma type injuries and sports injuries and a lot less of the RSI I saw so much of. So I think if you have not seen much it does not mean it doesn't exist, i think the incidence in your area is probably low because of the geographical, climate, and demographics of your area. I am sure people in the ski mountains of colorado see way more ACL than the surfers of california, and i am sure the surfer community sees way more AC joint problems, and so on.
Joined: August 29, 2007
I too have seen a few and have general concurrance with the tx's suggested. In addition I have found a foam roll for early home use to open anterior soft tissue structures can give some symptom relief and improved compliance for home work.