Chapter 6 Thoracic Outlet Syndrome Copyright 2012 Wolters

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Chapter 6: Thoracic Outlet Syndrome Copyright © 2012 Wolters Kluwer Health | Lippincott Williams

Chapter 6: Thoracic Outlet Syndrome Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Understanding thoracic outlet syndrome • Thoracic outlet is the space between the base of

Understanding thoracic outlet syndrome • Thoracic outlet is the space between the base of the anterior lateral neck and the axilla • Neurovascular bundle passes through thoracic outlet • Thoracic outlet syndrome is a collection of symptoms that occur when structures are compressed – Neurogenic outlet syndrome (compression of nerves) – Vascular outlet syndrome (compression of blood vessels) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -1 The thoracic outlet. The brachial, plexus, subclavian vein, and subclavian artery

Figure 6 -1 The thoracic outlet. The brachial, plexus, subclavian vein, and subclavian artery pass through the thoracic outlet. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common signs and symptoms • Symptoms begin gradually; are usually unilateral but may be

Common signs and symptoms • Symptoms begin gradually; are usually unilateral but may be bilateral • Aching, pain, burning, numbness, or tingling in the shoulder, neck, arm, or hand • Vascular thoracic outlet syndrome also causes swelling, ischemia, and sensitivity to temperature • Neck, chest, or jaw pain may occur • Frequent tension headaches • Disturbed sleep Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -2 Sleeping on one side. With the arm raised above the head

Figure 6 -2 Sleeping on one side. With the arm raised above the head during sleep, the brachial plexus and blood vessels can become compressed, producing symptoms and waking the client. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Possible causes and contributing factors • Cervical rib or other bony prominences • Use

Possible causes and contributing factors • Cervical rib or other bony prominences • Use of crutches • Postural imbalances • Hypertonicity and trigger points in the anterior and middle scalenes, subclavius, and pectoralis minor • Systemic disorders • Smoking, chronic respiratory disorders, coughing Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -3 Cervical rib. An extra rib can develop from the transverse process

Figure 6 -3 Cervical rib. An extra rib can develop from the transverse process of C 7, connecting to the lateral aspect of the first true rib. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Conditions commonly confused with or contributing to thoracic outlet syndrome • Herniated disc •

Conditions commonly confused with or contributing to thoracic outlet syndrome • Herniated disc • C 4 -5, C 5 -6, C 6 -7, C 7 -T 1 • Cervical spondylosis • Nerve root compression • Tendinitis • Pronator teres syndrome • Hypothyroid condition • Rheumatoid arthritis • Angina pectoris • Diabetes Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common conditions (continued) • Cervical stenosis • TMJ • Tumors • Raynaud’s syndrome •

Common conditions (continued) • Cervical stenosis • TMJ • Tumors • Raynaud’s syndrome • Shoulder injuries • Reflex sympathetic dystrophy syndrome • Carpal tunnel syndrome Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Contraindications and special considerations • Underlying pathologies • Reproducing symptoms • Edema • Hydrotherapy

Contraindications and special considerations • Underlying pathologies • Reproducing symptoms • Edema • Hydrotherapy • Treatment duration and pressure • Friction • Positioning • Tissue length • Mobilizations Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Massage therapy research • Barnes JF. (1996). Myofascial release in treatment of thoracic outlet

Massage therapy research • Barnes JF. (1996). Myofascial release in treatment of thoracic outlet syndrome. • Peng J. (1999). 16 cases of scalenus syndrome treated by massage and acupoint-injection. • Hamm M. (2006). Impact of massage therapy in the treatment of linked pathologies: scoliosis, costovertebral dysfunction, and thoracic outlet syndrome. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Working with the client • Client assessment – Health history – Postural assessment –

Working with the client • Client assessment – Health history – Postural assessment – ROM assessment: Active, passive, resisted – Special tests: Roos elevated art stress test, Adson’s test, costoclavicular maneuver, Wright’s test – Palpation assessment Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -4 Postural assessment comparison. Compare the anatomical posture on the left to

Figure 6 -4 Postural assessment comparison. Compare the anatomical posture on the left to the deviated posture on the right. Note how the shortened scalenes, subclavius, and pectoralis minor may contribute to compression of the contents in the thoracic outlet. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Condition-specific massage • May be difficult to pinpoint the area of compression • More

Condition-specific massage • May be difficult to pinpoint the area of compression • More than one area may be compressed • Treatment should be relaxing • Client should let you know if any treatment produces symptoms • Palpation of trigger point may cause referred pain • For acute injury, follow PRICE Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -9 Common trigger points and referral patterns associated with thoracic outlet syndrome.

Figure 6 -9 Common trigger points and referral patterns associated with thoracic outlet syndrome. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -10 Pectoral major. Short, tight pectorals contribute to the internal rotation of

Figure 6 -10 Pectoral major. Short, tight pectorals contribute to the internal rotation of the shoulder. Adapted from Clay JH, Pounds DM. Basic Clinical Massage Therapy, 2 nd ed. Philadelphia: Lippincott Williams & Wilkins, 2008. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -11 Subclavius. The subclavius may be adhered and hypertonic when the thorax

Figure 6 -11 Subclavius. The subclavius may be adhered and hypertonic when the thorax is flexed. Adapted from Clay JH, Pounds DM. Basic Clinical Massage Therapy, 2 nd ed. Philadelphia: Lippincott Williams & Wilkins, 2008. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -12 Pectoralis minor. The pectoralis minor may be shortened if the scapulae

Figure 6 -12 Pectoralis minor. The pectoralis minor may be shortened if the scapulae are protracted. Adapted from Clay and Pounds, 2008. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -13 SCM and scalenes. The SCM and scalenes may be short and

Figure 6 -13 SCM and scalenes. The SCM and scalenes may be short and tight. Adapted from Clay and Pounds, 2008. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -14 Scalene stretch. Passively stretch scalenes following trigger point therapy. Copyright ©

Figure 6 -14 Scalene stretch. Passively stretch scalenes following trigger point therapy. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -15 Latissimus dorsi, serratus anterior, and serratus posterior superior. Trigger points in

Figure 6 -15 Latissimus dorsi, serratus anterior, and serratus posterior superior. Trigger points in these muscles may mimic the pain involved in thoracic outlet syndrome. Adapted from Clay and Pounds, 2008. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 6 -16 Thoracic outlet syndrome treatment overview diagram. Follow the general principles from

Figure 6 -16 Thoracic outlet syndrome treatment overview diagram. Follow the general principles from left to right and top to bottom when treating thoracic outlet syndrome. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Client self-care • Perform self-care throughout the day • Take regular breaks from repetitive

Client self-care • Perform self-care throughout the day • Take regular breaks from repetitive actions or static postures • Gentle self-massage • Proper posture • Lift heavy loads with the legs instead of the back • Strengthening and stretching exercises Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Suggestions for further treatment • There should be some improvement with each session. If

Suggestions for further treatment • There should be some improvement with each session. If not, consider the following: – There is too much time between treatments – The client is not adjusting ADLs or not doing self-care – The condition is advanced or involves complications – The client has an undiagnosed underlying condition Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Thoracic Outlet Syndrome Elana Deacon Definition Thoracic outletThoracic Outlet Syndrome Elana Deacon Definition Thoracic outlet
Thoracic outlet syndrome for thoracic surgeons Bryan MThoracic outlet syndrome for thoracic surgeons Bryan M
Arterial complications of the thoracic outlet syndrome FiftyfiveArterial complications of the thoracic outlet syndrome Fiftyfive
Iatrogenic Thoracic Outlet Syndrome Secondary to VEPTR VerticalIatrogenic Thoracic Outlet Syndrome Secondary to VEPTR Vertical
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