Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

1. Etiology

   • entrapment of brachial plexus, arterial and venous structures combined or individually

2. Clinical Manifestations

   • paresthesias and pain in arm
   • tingling, paresis
   • (Upper Plexus) C5-C7 involvement: pain radiating to the face, anterior chest, scapulae, lateral aspect of forearm into the hand
     • difficulty with overhead and lifting activities, movements of head can aggravate sx in upper plexus
   • (Lower Plexus) C7-T1 involvement: pain and numbness in posterior neck and shoulder, medial arm and forearm, pain radiating to digits in the hand innervated by the ulnar nerve
   • atrophy in severe cases
   • Vascular sx
     • coldness
     • edema in arm or hand
     • Raynaud phenomenon
     • Fatigue in arm or hand
     • superficial vein distention

3. Types

   • Vascular TOS
     • compression of subclavian artery and/or vein
   • Neurogenic TOS
     • compression of brachial plexus
   • Nonspecific TOS
     • accompanied with chronic pain and sx of brachial plexus involvement

4. Differential Diagnosis

   • Carpal Tunnel
   • De Quervain's Tenosynovitis
   • Lateral epicondylitis
   • medial epicondylitis
   • complex regional pain syndrome
   • Horner's Syndrome
   • Raynaud's disease
   • Brachial plexus trauma
   • Glenohumeral joint instability
   • Thoracic (T4) Syndrome
   • Pancoast tumor

5. Medical Management

   • Surgery
     • Transaxillary approach
     • Supraclavicular approach
     • infraclavicular approach
     • Breast-reduction surgery
     • Decompression of clavicle or 1st rib
     • Vascular bypass
   • Physical Therapy
   • Pharmacologic
     • NSAIDS
     • Botulinum injections
     • Opioids
     • muscle relaxants
     • anticonvulsants

6. Risk Factors

   • postural changes (due to growth and development)
   • Trauma to shoulder girdle
   • body composition
   • congenital factors that affect bony structures (i.e fascial bands, 1st rib)
   • Affects more women than men

7. Prognosis

   • outcome is individual based
   • Majority will improve with PT interventions
   • vascular TOS and neurogenic TOS often requires surgery to relieve pressure on affected vessel or nerve