THORACIC OUTLET

SYNDROME (TOS)
DEFINITION
 DEFINITION/DESCRIPTION
► ‘Thoracic outlet syndrome’ describes compression of the neurovascular
structures as they exit through the thoracic outlet (cervicothoracobrachial
region).
► The thoracic outlet is marked by the anterior scalene muscle anteriorly, the
middle scalene posteriorly, and the first rib inferiorly.
► Two main categories of TOS: the vascular form (arterial or venous), which
raises few diagnostic problems, and the neurological form, which occurs in
more than 95-99% of all cases of TOS.
► Therefore the syndrome should be differentiated by using the terms arterial
TOS (ATOS), venous TOS (VTOS) or neurogenic (NTOS).
RELEVANT ANATOMY
 CLINICALLY RELEVANT ANATOMY

► The first narrowing area is the most proximal and is named the interscalene
triangle:
► This triangle is bordered by the anterior scalene muscle anteriorly, the middle
scalene muscle posteriorly, and the medial surface of the first rib inferiorly.
► The presence of the scalene minimus muscle and the fact that both the anterior
and middle scalene muscles have their insertion in the first rib (which can cause
overlapping) can cause a narrow space and therefore compression .
► The brachial plexus and the subclavian artery pass through this space
► The second passageway is called the costoclavicular triangle which is
bordered anteriorly by the middle third of the clavicle, posteromedially by the
first rib, and posterolaterally by the upper border of the scapula.
► The subclavian vein, artery and plexus brachialis crosses this costoclavicular
region and then further enters the subcoracoïd space.
► Just distal to the interscalene triangle.
Compression of these structures can occur as a result of congenital
abnormalities, trauma to the first rib or clavicle, and structural changes in the
subclavian muscle or the costocoracoid ligament.
► The last passageway is called the subcoracoid or sub-pectoralis minor space:
This last passageway is beneath the coracoid process just under the pectoralis
minor tendon.
► The borders of the thoraco-coraco-pectoral space include the coracoid process
superiorly, the pec minor anteriorly, and ribs 2-4 posteriorly.
► Shortening of the Pectoralis Major can lead to a narrowing of this last space and
therefore compression of the neurovascular structures during hyperabduction.
► Certain anatomical abnormalities can be potentially compromising to the
thoracic outlet as well. These include the presence of a cervical rib, congenital
soft tissue abnormalities, clavicular hypomobility , and functionally acquired
anatomical changes.
► Soft tissue abnormalities may create compression or tension loading of the
neurovascular structures found within the thoracic outlet (such as hypertrophy ,
a broader middle scalene attachment on the 1st rib or fibrous bands that increase
the stiffness,…).
ETIOLOGY
 EPIDEMIOLOGY/ETIOLOGY
► TOS affects approximately 8% of the population and is 3-4 times as frequent In woman as in men
between the age of 20 and 50 years.
► Females have less-developed muscles, a greater tendency for drooping shoulders owing to
additional breast tissue, a narrowed thoracic outlet and an anatomical lower sternum, these factors
change the angle between the scalene muscles and consequently cause a higher prevalence in
women.
► The mean age of people effected with TOS is 30s-40s; it is rarely seen in children. Almost all cases
of TOS (95-98%) affect the brachial plexus; the other 2-5% affecting vascular structures, such as
the subclavian artery and vein.
► There are several factors which can cause TOS: Cervical ribs are present in approximately
0.5-0.6% of the population, 50-80% of which are bilateral, and 10-20% produce symptoms; the
female to male ratio is 2:1.
► Cervical ribs and the fibromuscular bands connected to them are the cause of most neural
compression. Fibrous bands are a more common cause of TOS than rib anomalies.
 CONGENITAL FACTORS
► Cervical rib
► Prolonged transverse process
► Anomalous muscles
► Fibrous anomalies (transversocostal, costocostal)
► Abnormalities of the insertion of the scalene muscles
► Fibrous muscular bands
► Exostosis of the first rib
► Cervicodorsal scoliosis
► Congenital uni- or bilateral elevated scapula
► Location of the A. or V. Subclavian in relation to the M. scalene anterior
 ACQUIRED CONDITIONS
► Postural factors
► Dropped shoulder condition
► Wrong work posture (standing or sitting without paying attention to the physiological
curvature of the spine)
► Heavy mammaries
► Trauma
► Clavicle fracture
► Rib fracture
► Hyperextension neck injury, whiplash
► Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long
hours)
 MUSCULAR CAUSES
► Hypertrophy of the scalene muscles
► Decrease of the tonus of the M. trapezius, M. levator scapulae, M.rhomboids
► Shortening of the scalene muscles, M. trapezius, M. levator scapulae, pectoral muscles.
CLINICAL PRESENTATION
 CHARACTERISTICS/CLINICAL
PRESENTATION
► Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of
nerve and/or vessel involvement.
► Symptoms range from mild pain and sensory changes to limb threatening complications in severe
cases.
► Patients with thoracic outlet syndrome will most likely present pain anywhere between the neck,
face and occipital region or into the chest, shoulder and upper extremity and paresthesia in upper
extremity.
► The patient may also complain of altered or absent sensation, weakness, fatigue, a feeling of
heaviness in the arm and hand.
► The skin can also be blotchy or discolored. A different temperature can also be observed.
► Signs and symptoms are typically worse when the arm is abducted overhead and externally rotated
with the head rotated to the same or the opposite side.
► As a result activities such as overhead throwing, serving a tennis ball, painting a ceiling, driving, or
typing may exacerbate symptoms.
► When the upper plexus (C5,6,7) is involved there is pain in the side of the neck and this pain may
radiate to the ear and face.
► Often the pain radiates from the ear posteriorly to the rhomboids and anteriorly over the clavicle
and pectoralis regions.
► The pain may move laterally down the radial nerve area. Headaches are not uncommon when the
upper plexus is involved.
► Patients with lower plexus (C8,T1) involvement typically have symptoms which are present in the
anterior and posterior shoulder region and radiate down the ulnar side of the forearm into the hand,
the ring and small fingers.
 There are four categories of thoracic outlet syndrome and each presents with unique signs and
symptoms. Typically TOS does not follow a dermatomal or myotomal pattern unless there is nerve
root involvement, which will be important in determining PT diagnosis and planning treatment

Arterial TOS Venous TOS True TOS Disputed Neurogenic TOS

• Young adult • Younger men with • Hx of neck trauma • Hx of neck trauma

with vigorous vigorous arm activity • Pain, paresthesia, numbness, and/or • Pain, paresthesia, and
arm activity • Cyanosis weakness "feeling" of weakness
• Pain in the hand • Feeling of heaviness • Occipital headaches • Occipital headaches
• Claudication • Paresthesia in fingers • S/s present day and/or night • Nocturnal paresthesias that
• Pallor and hand (result of • Loss of fine motor skills often wake patient
• Cold intolerance edema) • Cold intolerance (possible • Loss of fine motor skills
• Paresthesias • Edema of the arm Raynaud's phenomenon) • Cold intolerance (possible
• S/s usually appear • Objective weakness Raynaud's phenomenon)
spontaneously • Compressors*: s/s day>night • Subjective weakness
• Releasers*: s/s night>day
► Compressors - a patient that experiences symptoms throughout the daytime
while using prolonged postures resulting in increased tension or compression
of the thoracic outlet.
► The most common aggravating postures are head forward with the shoulder
girdles protracted and depressed or activities that involve working overhead
with the arms elevated.
► These positions cause an increase in tension/compression (such as working
over head with elevated arms) that would result in an increase in tension or
compression of the neurovascular bundle of the brachial plexus
► Releasers - Describes patients that often experience parasthesia at night that
often wakes them up.
► It is caused by a release of tension or compression to thoracic outlet, that
restores the perineural blood supply to the brachial plexus, signalling a return
of normal sensation. This is used an indicator of a favourable outcome and
resolution of symptoms.
DIAGNOSIS AND EXAMINATION
 DIAGNOSTIC PROCEDURES
► The diagnosis of TOS is essentially based on history, physical examination,
provocative tests, and if needed ultrasound, radiological evaluation and
electrodiagnostic evaluation.
► It must always kept in mind that TOS diagnosis is usually confirmed by elimination
of other causes with similar clinical presentation. Especially differential diagnosis
of cervical radiculopathies and upper extremity entrapment neuropathies can be
hard (McGillicuddy 2004).
► In order to diagnose accurately, the clinical presentation must be evaluated as either
neurogenic (compression of the brachial plexus) or vascular (compression of the
subclavian vessels). TOS manifestations are varied and there is no single definitive
test, which makes it difficult to diagnose.
 EXAMINATION
► The following includes common examination findings seen with TOS that should be evaluated;
however, this is not an all-inclusive list and examination should be individualized to the patient.
► History
► Thorough history, clear any red flags, and ask the patient how signs/symptoms have affected
his/her function.
► Type of symptoms
► Location and amplitude of symptoms
► Irritability of symptoms
► Onset and development over time
► Aggravating/alleviating factors
► Disability
► Physical Examination
► Observation
► Posture
► Cyanosis
► Edema
► Paleness
► Atrophy
► Palpation
► Temperature changes
► Supraclavicular fossa
► Scalene muscles (tenderness)
► Trapezius muscle (tenderness)
► Neurological Screen
► MMT & Flexibility of following muscles:
► Scalene
► Pectoralis major/minor
► Levator scapulae
► Sternocleidomastoid
► Serratus anterior
 SPECIAL TESTS
Elevated Arm Stress/
Roos test Adson's
The patient has arms at The patient is asked to
90° abduction and the rotate the head and elevate
therapist puts downwards the chin toward the
pressure on the scapula as affected side. If the radial
the patient opens and pulse on the side is absent
closes the fingers. If the or decreased then the test
TOS symptoms are is positive, showing the
reproduced within 90 vascular component of the
seconds, the test is neurovascular bundle is
positive. compressed by the scalene
muscle or cervical rib.
Wright's
The patient’s arm is hyper
abducted. If there is a
decrease or absence of a
pulse on one side then the
test is positive, showing
the axillary artery is
compressed by the
pectoralis minor muscle or
coracoid process due to
stretching of the
neurovascular bundle.
 SPECIAL TESTS
Cyriax Release
The patient is seated or
standing. The examiner
stands behind patient and
grasps under the forearms,
holding the elbows at 80
degrees of flexion with the
forearms and wrists in
neutral. The examiner leans
the patient’s trunk posteriorly
and passively elevated the
shoulder girdle. This position
is held for up to 3 minutes.
The test is positive when
paresthesia and/or numbness
(release phenomenon) occurs,
including reproduction of
symptoms.
Supraclavicular
Pressure
The patient is seated with
the arms at the side. The
examiner places his fingers
on the upper trapezius and
thumb on the anterior
scalene muscle near the
first rib. Then the
examiner squeezes the
fingers and thumb together
for 30 seconds. If there is a
reproduction of pain or
paresthesia the test is
positive, this addresses
compromise to brachial
plexus through scalene
triangles.
Costoclavicular
Maneuver
This test may be used for
both neurological and
vascular compromise. The
patient brings his
shoulders posteriorly and
hyperflexes his chin. A
decrease in symptoms
means that the test is
positive and that he
neurogenic component of
the neurovascular bundle
is compressed.
 SPECIAL TESTS
Upper Limb Tension
► These tests are designed to put stress
on neurological structures of upper
limb. The shoulder, elbow, forearm,
wrist and fingers are kept in specific
position to put stress on particular
nerve (nerve bias) and further
modification in position of each joint
is done as "sensitizer".
Cervical Rotation Lateral
Flexion
► The test is performed with the patient
in sitting. The cervical spine is
passively and maximally rotated
away from the side being tested.
While maintaining this position, the
spine is gently flexed as far as
possible moving the ear toward the
chest. A test is considered positive
when the lateral flexion movement is
blocked.
 SPECIAL TESTS

Elevated Arm Stress/

Roos test Adson's Wright's
 SPECIAL TESTS

Supraclavicular Costoclavicular
Cyriax Release Pressure Maneuver
 SPECIAL TESTS

Cervical Rotation Lateral

Upper Limb Tension Flexion
► Electrodiagnostic evaluation and imaging
► Nerve conduction studies and electromyography are often helpful as
components of the diagnostic evaluation of patients with suspected TOS.
Nerve conduction studies usually reveal decreased ulnar sensorial potentials,
decreased median action potentials, normal or close to normal ulnar motor and
median sensorial potentials. Vascular TOS can be identified with venography
and arteriography.
Besides the electrophysiological studies, imaging studies can provide useful
information in the diagnosis of TOS. Cervical spine and chest x-rays are
important in the identification of bony abnormalities (such as cervical ribs or a
“peaked C7 transverse processes)
MEDICAL AND SURGICAL
MANAGEMENT
 MEDICAL MANAGEMENT
► Nonsteroidal anti-inflammatory drugs have been prescribed to reduce pain and
inflammation. Botulinum injections to the anterior and middle scalenes have also found
to temporarily reduce pain and spasm from neurovascular compression, further research
is needed because there are discrepancies in the literature.
► Surgical management of TOS should only be considered after conservative treatment
has been proven ineffective.
 SURGICAL MANAGEMENT
► limb-threatening complications of vascular TOS have been indicated for surgical intervention.
Surgery to treat thoracic outlet syndrome, may be performed using several different approaches,
including: transaxillary approach, supraclavicular approach and infraclavicular approach.
► Transaxillary approach. The first rib forms the common denominator for all causes of nerve and artery
compression in this region, so that its removal generally improves symptoms. Surgeon makes an
incision in the chest to access the first rib, divide the muscles in front of the rib and remove a portion
of the first rib to relieve compression, without disturbing the nerves or blood vessels.
► Supraclavicular approach has been advocated to perform first rib resection and scalenectomy, a safe
and effective procedure, characterized by a shorter operative time and having a complication rate
lower or comparable to that of transaxillary first rib resection.
This approach repairs compressed blood vessels. The surgeon makes an incision just under the neck
to expose the brachial plexus region. Then looks for signs of trauma or muscles contributing to
compression near the first rib. The first rib may be removed if necessary to relieve compression.
► Infraclavicular approach. In this approach, the surgeon makes an incision under the collarbone and across
the chest. This procedure may be used to treat compressed veins that require extensive repair.
► Neurogenic TOS: Surgical decompression should be considered for those with true neurological signs or
symptoms. These include weakness, wasting of the hand intrinsic muscles, and conduction velocity less
than 60 m/sec. The first rib can be a major contributor to TOS. There is controversy, however, regarding
the necessity of a complete resection to reduce the chance of reattachment of the scalenes, scar tissue
development, or bony growth of the remaining tissue. In addition to the first rib, cervical ribs are
removed, scalenectomies can be performed, and fibrous bands can be excised. Terzis found that the
supraclavicular approach to treatment to be an effective and precise surgical method
► Arterial TOS: Decompression can include cervical and/or first rib removal and scalene muscle revision.
The subclavian can then be inspected for degeneration, dilation, or aneurysm. Saphenous vein graft or
synthetic prosthesis can then be used if necessary
► Venous TOS: Thrombolytic therapy is the first line of treatment for these patients. Because of the risk of
recurrence, many recommend removal of the first rib is necessary even when thrombolytic therapy
completely opened the vein. The results of a study show that infraclavicular approach is a safe and
effective treatment for acute VTOS. They had no brachial plexus or phrenic nerve injuries.
► Angioplasty can then be used to treat those with venous stenosis
► In venous or arterial TOS, medication can be administered to
dissolve blood clots prior to thoracic outlet compression. It may also
be to conduct a procedure to remove a clot from the vein or artery or
repair the vein or artery prior to thoracic outlet decompression.
► Some larger-chested women have sagging shoulders that increase
pressure on the neurovascular structures in the thoracic outlet. A
supportive bra with wide and posterior-crossing straps can help
reduce tension. Extreme cases may resort to breast-reduction surgery
to relieve TOS and other biomechanical problems.
PHYSICAL THERAPY MANAGEMENT
 PHYSICAL THERAPY MANAGEMENT
► Conservative management should be the first strategy to treat TOS since this seems to be effective at
decreasing symptoms, facilitating return to work and improving function, but yet a few studies have evaluated
the optimal exercise program as well as the difference between a conservative management and no treatment.
► Conservative management includes physical therapy, which focuses mainly on patient education, pain control,
range of motion, nerve gliding techniques, strengthening and stretching.
► Stage 1:
► The aim of the initial stage is to decrease the patient’s symptoms.
► This may be achieved by patient education, in which TOS, bad postures, the prognosis and the importance of
therapy compliance are explained.
► Furthermore some patients who sleep with the arms in an overhead, abducted position should get some
information about their sleeping posture to avoid waking up at night.
► These patients should sleep on their uninvolved side or in supine, potentially by pinning down the sleeves. The
Cyriax release test may be used if a ‘release phenomenon’ is present. This technique completely unloads the
neurovascular structures in the thoracic outlet before going to bed.
► Cyriax Release Maneuver
► Elbows flexed to 90°
► Towels create a passive shoulder girdle elevation
► Supported spine and the head in neutral
► The position is held until peripheral symptoms are produced. The patient is
encouraged to allow symptoms to occur as long as can be tolerated up to 30
minutes, observing for a symptom decrescendo as time passes.
► The patient’s breathing techniques need to be evaluated as the scalenes and other
accessory muscles often compensate to elevate the ribcage during inspiration.
Encouraging diaphragmatic breathing will lessen the work load on already
overused or tight scalenes and can possibly reduce symptoms.
► Scapula Settings and Control
► In the treatment first have to start with scapula settings and control.
► This is important to establishing normal scapula muscle recruitment and control in the
resting position. Once this is achieved then the program is progressed to maintaining
scapula control while both motion and load are applied. The programme begins in lower
ranges of abduction and is gradually progressed further up into abduction and flexion range
until muscles are being retrained in functional movement patterns at higher ranges of
elevation.
► Control the Humeral Head Position
► It is also important to control the humeral head position. Specific drills are given to facilitate humeral
head control. The most common aberrant position of the humeral head is an increase in anterior
placement of the humeral head. A useful strategy to help facilitate co-contraction of the rotator cuff to
help stabilize and centralize the humeral head is to facilitate a mid level isometric contraction of the
rotator cuff by applying resistance to the humeral head (Dark et al., 2007).
► Further on in the treatment this may be integrated into movement patterns. First in slow controlled
concentric/eccentric motion drills, later isolated muscle strengthening drills.

► Serratus Anterior Recruitment and Control

► Abduction external rotation strategies described above are often sufficient to trigger serratus anterior
recruitment and control without the risk of over-activating pectoral minor muscle
► Stage 2:
► Once the patient has control over his/her symptoms, the patient can move to this stage of treatment. The
goal of this stage is to directly address the tissues that create structural limitations of motion and
compression. How this should be done is one of the most discussed topics of this pathology. Some
examples of methods that are used in the literature are.
► Massage
► Strengthening of the levator scapulae, sternocleidomastoid and upper trapezius (This group of muscles
open the thoracic outlet by raising the shoulder girdle and opening the costoclavicular space)
► Stretching of the pectoralis, lower trapezius and scalene muscles (These muscles close the thoracic
outlet)
► Postural correction exercises
► Relaxation of shortened muscles
► Aerobic exercises in a daily home exercise program
► Exercises
► Shoulder exercises to restore the range of motion and so provide more space for the neurovascular
structures.
Exercise: Lift your shoulders backwards and up, flex your upper thoracic spine and move the shoulders
forward and down. Then straightened the back and repeat 5 to 10 times.
► ROM of the upper cervical spine
Exercise: Lower your chin 5 to 10 times against your chest, while you are standing with the back of your
head against a wall. The effectiveness of this exercise can be enlarged by pressing the head down by
hands.
► Activation of the scalene muscles are the most important exercises. These exercises help to normalize
the function of the thoracic aperture as well as all the malfunctions of the first rib. Exercises are Anterior
scalene (Press your forehead 5 times against the palm of your hand for a duration of 5 seconds, without
creating any movement), Middle scalene (Press your head sidewards against your palm), Posterior
scalene (Press your head backwards against your palm
► Stretching exercises
► Other Interventions
► Repositioning/mobilization of the shoulder girdle and pelvis joints: cervicothoracic, sternoclavicular,
acromionclavicular, and costotransverse joints
► Glenohumeral mobilizations in end-range elevation with the elbow supported in extension
► Taping: some patients with severe symptoms respond to additional taping, adhesive bandages or braces that elevate
or retract the shoulder girdle.
► Manipulative Treatment to Mobilize the First Rib
► These should be carried out with caution and only after a thorough assessment as they can provoke irritation and
pain symptoms in some patients
► Posterior Glenohumeral Glide with Arm Flexion:
The patient is supine. The mobilizisation hand contacts the proximal humerus avoiding corocoid process. The force
is directed posterolaterally (direction of thumb).
► Anterior Glenohumeral Glide with Arm Scaption:
The patient is prone. The mobilization hand contacts the proximal humerus avoiding acromion process. The force is
directed anteromedially.
► Inferior Glenohumeral Glide:
The patient is prone. The stabilizing hand holds the proximal humerus the humerus distal to the lateral acromion
process. The mobilization hand contacts the axillary border of the scapula. Mobilize the scapula in a craniomedial
direction along the ribcage.
 Exercise Muscles Targeted

Scapular retraction - Rhomboids

- Trapezius

Scapular depression - Trapezius (lower)

- Latissimus dorsi
- Rhomboids
Standing external rotation - Trapezius (lower)
“No Money” - Infraspinatus
- Teres minor
- Subscapularis
straight arm extension - Latissimus dorsi
- Teres major
- Triceps brachii

Banded high rows - Latissimus dorsi

- Trapezius
- Rhomboids
- Teres major/minor
 Exercise Muscles Targeted

Prone shoulder extension, abduction, horizontal - Rhomboids

abduction - Trapezius
“I’s, Y’s and T’s” - Supraspinatus
- Infraspinatus
- Deltoid
- Latissimus dorsi
- Teres major
Frontal raise Deltoid

Lateral raise - Deltoid

- Supraspinatus
- Trapezius
Serratus push Serratus anterior

Chin tuck Trapezius