Thoracic outlet syndrome remains one of the most controversial clinical entities in medicine because there is not much agreement as to what exactly constitutes thoracic outlet syndrome. 1,2
Assessment
Diagnosing and treating thoracic outlet syndrome can be challenging and frustrating, because the clinical presentation is highly variable, depending on what structures are involved (vascular or neurogenic).3 TOS can be categorized into four clinical entities: venous, arterial, true neurogenic, and disputed neurogenic.4The mechanism of nerve irritation in disputed neurogenic TOS can occur from brachial plexus compression, stretching, or some combination of both.5 Yet, it is possible to make an accurate diagnosis and to plan specific, effective conservative management, particularly for those that suffer from disputed neurogenic TOS.3 An exhaustive history and physical examination are essential and may require a team of physicians and therapists.3 A physical exam should include, but may not be limited to: cervical spine screen; Elevated Arm Stress test (to identify compression of the brachial plexus); Cyriax Release test (to identify stretching of the brachial plexus); Cervical rotation lateral flexion test (to identify an elevated first rib); Nerve tension test; Assessment of posture and dynamic scapular control; Assessment of active/passive mobility of the elevation chain (SCJ, ACJ, GHJ, Scapulothoraic Jt, and Cervicothoracic Junction); and Manual muscle tests of GHJ and scapular stabilizers.
Therapy
Therapy is effective at reducing symptoms, improving function, and facilitating return to work.6 A current study showed that 94% of patients had relief of symptoms of neurogenic thoracic outlet with therapy.7 Another recent study also suggests that there is a high association of disturbances in the thoracic outlet in patients with carpal tunnel syndrome, and evaluation of proximal structures in persons with carpal tunnel syndrome has clinical merit.8
1Povlsen B et al. Treatment of thoracic outlet syndrome. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007218.
2Wehbe M. Thoracic outlet syndrome. Hand Clin. 2004 Feb;20(1):xi.
3Brantigan CO, Roos DB. Diagnosing thoracic outlet syndrome. Hand Clin. 2004 Feb;20(1):27-36
4Watson LA et al. Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways. Manual Therapy 2009;14:586-595.
5Ide J et al. Compression and stretching of the brachial plexus in thoracic outlet syndrome: correlation between neuroradiographic findings and symptoms and signs produced by provocation maneuvers. J Hand Surg Br. 2003 Jun:28(3):218-223.
6Vanti C et al. Conservative treatment of thoracic outlet syndrome. A review of the literature. Eura Medicophys. 2007 Mar;43(1):55-70.
7Hanif S et al. Role of therapeutic exercises in neurogenic thoracic outlet syndrome. J Ayub Med Coll Abbottabad. 2007 Oct-Dec;19(4):85-8.
8Vaught M et al. Association of disturbances in the thoracic outlet in subject with carpal tunnel syndrome: a case-control study. J Hand Ther. 2011 Jan-Mar:24(1):44-51.
