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ThoracicOutletSyndrome
Thoracicoutletsyndrome(TOS)isasyndrome/conditionthatencompassesclusterofupperextremity
symptomswhichareduetocompressionoftheneurovascularbundlebyvariousstructuresintheareajust
abovethefirstribandbehindtheclavicle.Thethreemostcommonregionswherecompressionsisthought
tooccuristheintrascalenetriangle,thecostoclaviculartriangleandthesubcoracoidspace.
Thetermthoracicoutletsyndromedescribesaclusterofsymptomssittingonacontinuumrangingfrom
intermittedposturalsymptomstosevere/permanentneurological/vasculardeficits.(Hooper,Denton,
McGalliard,etal.,2010aSanders,Hammond,&Rao,2007Watson,Pizzari,&Balster,2009,Kaczynski,&
Fligelstone,2013)
Thoracicoutletsyndromewasfirstdescribedin1927byAdsonandcolleaguesandknownatthistimeas
scalenusanticussyndrome.TheformaltermthatmostauthorsreferstoasThoracicoutlet
syndromewasderivedbyPeetandcolleaguesin1956.WhenreviewingliteratureinthetopicofTOSkeep
anopenmindthattheconditionitselfandsubjectpopulationareoftenpoorlydefinedandvaryenormously
betweenstudies.Thisleadstopoorstudyresultsduetotheheterogeneityofthestudypopulation.

IfyouarereadingaboutTOSyoumightnoticedthatthereisalwaysanelementofcontroversyaboutit's
definition,diagnosisandtreatment.Let'stakealookatthesepointsofcontroversyincloserdetail.Thefirst
pointofcontroversyisthatthedefinitiondoesnotspecifywhereorwhatorhowcompression
occurs.ThesecondpointofcontroversyrevolvesaroundthediagnosisofsymptomaticTOS,whereno
radiologicalorelectrophysicalabnormalitiescanbedetectedandthepathologicalcauseforsymptomsis
unknown.Diagnosiswillrelyheavilyonphysicalexaminationandcollectionofobjectiveasterisksignsfor
reproductionofsymptoms.And,thethirdpointofcontroversyisaboutthelackofacleardefinitionofthe
clinicalpresentationofTOS.Manypatientsmaypresentwithaclusterofarterial,venous,neurogenicand
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painsymptomsanddiagnosisreliesonclinicalreasoningoftheassessingtherapist.Belowaresomeofthe
keyfeaturesofTOSthatIfoundconsistentlythroughouttheliteraturetobepresentinthiscondition.

ClassificationofThoracicoutletsyndrome
Inthecurrentresearchtrials,thoracicoutletsyndromeisbeingclassifiedintothefollowingcategories:
1.ThefirstcategoryisVascularTOS,whichincludesarterialandvenousandaccountsfor~5%ofall
presentations.
2.ThesecondcategoryisNeurologicalTOS,whichisbrokendownfurtherintotrueandsymptomatic
TOS.
3.SymptomaticTOScomprisesover80%ofallpeoplepresentingwiththisdiagnosis.Thatistosay
thereisahugeproportionofpatientswillpresentwithnoradiologicalorelectrophysicalabnormality
(Hooperetal.,2010aSandersetal.,2007Kaczynskietal.,2013).

Aetiology
ThereareanumberofreasonsthatTOScanoccur.Mostofthetime,regardlessofthemechanism,
symptomsarecausedduetoanalterationintheshapeofthethoracicoutlet.Thisisreferredtoinmore
recentstudiesascontainerdysfunction(Hooper,etal.,2010a).
InthestudybyKaczynskiandcolleagues(2013),whichassessedthecauseofcompressioninpatientswith
vascularandtrueneurologicalTOS,over80%werefoundtohavefibrousmuscularbandsand
hypertrophicscalenemuscle.Cervicalribsandabroadenedfirstribonlyfoundin3%of
patients.However,inpatientswithsymptomaticTOSthesestructuralanomaliesareoftennotfound.
Itisspeculatedtherefore,thatthemechanismofsymptomsrelatestoalteredbreathingmechanics,postural
dysfunction,scapulardyskinesia,muscularimbalancesandneuraltension.
Theprevalenceisthoughttobe8%inthegeneralpopulationandpresentbetweentheagesof1860+
yearsold.Womenare34timesmorelikelytosufferfromTOSsymptomsandthisconditionsisrarelyseen
inchildren.Itisreportedinupto50%ofcasesofCarpalTunnelsyndrome,asdoublecrush
syndrome(Hooper,etal.,2010aWatson,etal.,2009).

Diagnosis&Clinicalpresentation
Thediagnosisofthoracicoutletsyndromeremainsdisputedasthereisnostandardobjectivetesttoconfirm
clinicalimpressions.Itremainsadiagnosisofexclusion(Hooper,etal.,2010,p.76).
Diagnosisofsymptomaticthoracicoutletsyndromeisdependentonasystematic,comprehensiveupper
bodyexamination(Watsonetal,2009,p.588).
Watsonandcolleaguesprovideatwopartmasterclasswhichcomprehensivelyoutlinesthemusculoskeletal
examinationrequiredtoarriveatthediagnosisofTOS,andprovidetreatmentstrategiestomanage
scapulardyskinesia,muscularimbalancesandimprovecontainerdysfunction.Itwasoneofthebestsources
Icameacrossinthisbodyofresearchandapplicabletoeverydayclinicalpractice.Forfurtherreadingon
clinicalpresentation,diagnosisandmanagementIwouldreferyoutothesetwoarticles.
Watson,L.A.,Pizzari,T.,&Balster,S.(2009).Thoracicoutletsyndromepart1:Clinicalmanifestations,
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differentiationandtreatmentpathways.Manualtherapy,14(6),586595.
Watson,L.A.,Pizzari,T.,&Balster,S.(2010).ThoracicoutletsyndromePart2:Conservative
managementofthoracicoutlet.Manualtherapy,15(4),305314.

Distributionofsymptoms
Symptomscaninvolvethehead,neck,thoraxandupperlimb.Besuretomapthedistributionofsymptoms
carefullyonabodychartasthismayhelpwithdifferentialdiagnosis(Hooperetal,2010a).Tofurther
understandthedifferencebetweenarterial,venous,neurogenicandpainsymptomsIwouldrecommend
Hopperetal(2010a),whoprovideacleartableoutliningtheindividualsymptomsandcrossoverbetween
categories.
Arterialsymptoms:pain(mostlyinthehand),numbnesswhichisnonradicular,coolnesstotouch,cold
intoleranceandpalediscolouration.Mostlyseeninayoungerpopulationinvolvedinrepetativeoverhead
activity.
Venoussymptoms:excruciatingchestpain,cyanoticdiscolouration,distendedcollateralveinsand
oedemaintheextremity.
NeurogenicSymptoms:pain,paraesthesia,numbnessandweaknessinvolvingtheneck,shoulderand
upperlimb.Symptomsareoftenprecededbynecktrauma,MVAorrepetativestressthroughwork/sport.
TrueneurologicalweaknesswillbepresentintrueTOS,whilemanyhavesymptomsofclumsinessand
lossofdexterity.
Pain
Paraesthesiaismostcommonlyreportedinthe4thand5thfingersifthelowertrunkofthebrachial
plexusisinvolved.Dependingwhenthecompressionofthebrachialplexusoccurswillcausevariationin
symptoms.
Establishseverity,irritability,nature,and24hourbehaviour.Aggravatingpositions
Sustainedshoulderelevationorsustainedactivities.
Repetitiveuseoftheupperlimb.
Lyingonthearm.
Carryingabagorbackpack.
Prolongedpostures.
Physicalexaminationislongandrequiresacomprehensiveassessmentofthecervicalandthoracicspine
andupperquadrant,including:
Activeandpassiverangeofmovementlookingforreproductionofsymptoms.
Breathingtechnique
Restingpostureandobservationofskindiscolourationorswelling.
Assessmentofscapularmotorcontrol.
Upperlimbneurodynamicassessment
Upperlimbneurologicalexamination.
Palpation,inparticularthecervicalspineandsupraclavicularfossa.
Shoulderspecialtestingforrotatorcuffpathologyandglenohumeraljointinstability.
Peripheralnervetesting(forcarpaltunnelsyndromeandotherperipheralentrapmentneuropathies).
Musclelengthandstrengthofthecervicobrachialmuscles.
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PainProvocationtests
AsmentionedabovethereisnostandardclinicaltestthatconfirmsthediagnosisofTOS.Therearehowever
fiveavailablepainprovocationtestswhichcanbeusedasagroupofteststoprovidesymptoms.Noneof
thesetestsarevalidasasingleentitybutstudieshavebeenconductedthatshow34positivetestshavea
sensitivityof8590%andspecificityof~30%.Toincreasethespecificityto84%youneedallfivepositive
tests(Gillard,PerezCousin,Hachulla,etal.,2001,p.419).ForfurtherdetailonthesetestsrefertoAbdul
Jadar,2009andWatson,etal.,2009.
Wright'stest
Knownalsoasthehyperabductionmanoeuvre.
Thearmisheldin90degreesabductionandexternalrotation,45degreeselbowflexionand
sustainedfor1minute.
Adson'stest
Thepatientholdstheirarmtothesideandturnstheheadtofullrotationandextensiontothe
ipsilateralside.Thepatientisaskedtobreatheindeeply.
Costoclaviculartest
Thepatientispositionedinscapularetraction,depression,elevationandprotractionandheldineach
positionforupto30seconds.
RoosTest
Performedbyholdingbotharmsinanelevatedandabductedpositionwithelbowsbentto90
degrees.
Thepatientistheninstructedtoopenandclosetheirhandsrepeatedlyfor3minutes.
Onethingtokeepinmindisthattheabovetestsisthatwhentheclinicalvaliditywasexamineditwasdone
soonhealthyindividuals.Meaningthat,manypeoplewillhaveapositivetestwithoutsymptomsandthereis
nonormativedataavailableforthesetests.Asecondpointtokeepinmindisthatthetestsareconsidered
positiveifthereisanobliterationoftheradialpulse.Tosustainthetestuntilthepulseislostmaybe
unnecessaryandtooaggressive.Manyauthorsnowsuggestperformingthemuntilreproductionof
symptoms.

ClinicalPredictionRule
Lindrenetal(1997)producedaclinicalpredictionrulestatingthattheclinicaldiagnosiscanbemadewithat
leastofthefollowingsymptoms
1.Aggravationwitharminelevatedposition.
2.ParaesthesiaoriginatingfromC8/T1.
3.Supraclaviculartendernessoverbrachialplexus.
4.PositiveRoostest.
WithcurrentresearchweknowthatamorethoroughexaminationisrequiredandGillardetal(2001)
suggest34positivepainprovocationtestsinthisrule.Thisclinicalpredictionrulecanstillbeimplemented
asaroughguidelinebyclinicianstoaidintheclinicalreasoningprocess.

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Followingtheextensivephysicalexaminationthereshouldbeenoughobjectivemeasurestakentoallowfor
differentialdiagnosisofthefollowingconditions.Oftenpatientswillbereferredforfurtherdiagnostic
measuressuchasMRI,nerveconductionstudies,dopplerultrasound,angiography,venousultrasound,
HelicalCTangiographyandevenplainXRAYtofurtherinvestigatethedegreeofneurovascularcompromise
andidentifyanycontributingpathoanatomy.Itisimportanttorememberthannosingletestcanbe
usedasastandardreference.
Differentialdiagnosis(Watsonetal.,2009,p.589):
Carpaltunnelsyndromeorotherperipheralneuropathies.
DeQuervain'stenosynovitis.
Lateralepicondylalgia&Medialepicondylalgia.
Complexregionpainsyndrome.
Horner'ssyndrome.
Raynaurd'sdisease.
Cervicalspinediscpathology,spondylolisthesisorspondylosiscausingcervicalradiculopathy
Brachialplexustrauma.
Systemicinflammatorydiseaseorcardiacdisease.
Upperextremitydeepveinthrombosis.
PagetsSchroettersyndrome.
Rotatorcuffpathology.
Glenohumeraljointinstability.
Thesecondpartofthisblogwillcoverinformationregardingthecurrenttrendsinphysiotherapy
managementforThoracicoutletsyndromeincludingscapularretrainingandclinicalneurodynamics.
Sian
References:
AbdulJabar,H.,Rashid,A.,&Lam,F.(2009).Thoracicoutletsyndrome.OrthopaedicsandTrauma,23(1),
6973.
Gillard,J.,PerezCousin,M.,Hachulla,E.,Remy,J.,Hurtevent,J.F.,Vinckier,L.,etal.(2001).Diagnosing
thoracicoutletsyndrome:contributionofprovocativetests,ultrasonography,electrophysiology,andhelical
computedtomographyin48patients.Jointbonespine,68(5),416424.
Hooper,T.L.,Denton,J.,McGalliard,M.K.,Brisme,J.M.,&SizerJr,P.S.(2010).Thoracicoutlet
syndrome:acontroversialclinicalcondition.Part1:anatomy,andclinicalexamination/diagnosis.TheJournal
ofmanual&manipulativetherapy,18(2),74.
Hooper,T.L.,Denton,J.,McGalliard,M.K.,Brismee,J.M.,&Sizer,P.S.,Jr.(2010).Thoracicoutlet
syndrome:acontroversialclinicalcondition.Part2:nonsurgicalandsurgicalmanagement.TheJournalof
manual&manipulativetherapy,18(3),132138.
Kaczynski,J.,&Fligelstone,L.(2013).SurgicalandFunctionalOutcomesAfterThoracicOutletSyndrome
DecompressionviaSupraclavicularApproach:A10YearSingleCentreExperience.JournalofCurrent
Surgery,3(1),712.
Lindgren,K.A.(1997).Conservativetreatmentofthoracicoutletsyndrome:a2yearfollowup.Archivesof
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physicalmedicineandrehabilitation,78(4),373378.
Mackinnon,S.E.,&Novak,C.B.(2002).Thoracicoutletsyndrome.CurrentProblemsinSurgery,39(11),
10701145.
Peet,R.M.,Henriksen,J.D.,Anderson,T.,&Martin,G.M.(1956).Thoracicoutletsyndrome:evaluationof
atherapeuticexerciseprogram.PaperpresentedattheProceedingsofthestaffmeetings.MayoClinic.
Roos,D.B.(1990).Thethoracicoutletsyndromeisunderrated.Archivesofneurology,47(3),327.
Sanders,R.J.(2013).AnatomyoftheThoracicOutletandRelatedStructuresThoracicOutletSyndrome
(pp.1724):Springer.
Sanders,R.J.,Hammond,S.L.,&Rao,N.M.(2007).Diagnosisofthoracicoutletsyndrome.Journalof
vascularsurgery,46(3),601604.
Watson,L.A.,Pizzari,T.,&Balster,S.(2009).Thoracicoutletsyndromepart1:Clinicalmanifestations,
differentiationandtreatmentpathways.Manualtherapy,14(6),586595.
Watson,L.A.,Pizzari,T.,&Balster,S.(2010).ThoracicoutletsyndromePart2:Conservativemanagement
ofthoracicoutlet.Manualtherapy,15(4),305314.

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