Thoracic Outlet Syndrome

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THE JOURNALOF ORTHOPAEDIC AND SPORTSPHYSICALTHERAPY
Copyright O 1979 by The Orthopaedic and Sports Medicine Sections 01 the
American Physical Therapy Association
The Thoracic Outlet Syndrome:

A Protocol of Treatment *
KENNETH F. SMITH,? ,$ BS, PT
A protocol of treatment for the physical therapy management of the thoracic outlet
syndrome has been established at Amsterdam Memorial Hospital, Amsterdam,
New York. Certain orthopaedic manual therapy procedures are utilized to increase
the mobility of specific areas of the patient's shoulder girdle, upper thorax, and if
indicated, the cervical and upper thoracic spine. Previous training in orthopedic
manual therapy is a prerequisite to employing this approach to the treatment of
the thoracic outlet syndrome. A total of eight anatomical structures are involved.
This particular regime of manual therapy plus postural improvement, corrective
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exercises, improved body mechanics, and other procedures relating to the

patient's activities of daily living have proven to be an effective method to relieve
the signs and symptoms produced by this musculoskeletal entity. Paraesthesiae
and numbness were the predominant symptoms of the patients that underwent
treatment. The patients ranged in age from 2 7-60 years.
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
The neurovascular structures that are involved have been described in the literature over a
in this compression syndrome are the lower number of years.'-7 Lord and Rosati' believe that
cords of the brachial plexus and the subclavian the costoclavicular area is a major source of
artery and vein. The signs and symptoms en- difficulty in the TOS, even when diagnostic stud-
countered in the upper extremity may include ies appear to indicate otherwise. Therefore, a
paraesthesia, numbness, pain, edema, muscle major part of this treatment approach is directed
weakness, claudication, discoloration, tempera- toward this area. The treatment concept is based
Journal of Orthopaedic & Sports Physical Therapy®
ture and tropic changes, ulceration, gangrene, upon the following: as the neurovascular struc-
and, in some cases, Raynaud's phenomenon. tures are compressed between the 1st rib and
The symptomatology varies according to the par- clavicle, the pressure is relieved by first, restor-
ticular structures that are being compressed or ing (or increasing) the accessory joint movement
irritated as well as the frequency, duration, and at the sternoclavicular and acromioclavicular
degree of compression. The various causes of joints; second, increasing the mobility of the 1st
thoracic outlet syndrome (TOS) are well docu- and 2nd ribs; and third, relieving muscle tension
mented,'-7 e.g., cervical rib, fibrous or muscular in the shoulder girdle musculature and restoring
band, hypertrophied scalene muscles, postural any loss of muscle elasticity. Subsequently, the
abnormalities, to mention only a few. The primary clavicle (or "roof" of the compression compart-
purpose of this paper is to present a program of ment) and the 1st rib (the "floor" of the com-
treatment management. The pathology, signs, partment) are given greater separation. The cos-
and symptoms of the specific aspects of the TOS toclavicular space is enlarged and the compres-
sion of the neurovascular bundle is reduced or
eliminated. Although the separation of these bo-
* This protocol of treatment for the physical therapy management of ney structures is minimal, this increase in space
the thoracic outlet syndrome was presented at the Humera Society is sufficient to reduce significantly the pressure
Meeting in Bermuda on April 23. 1976 and as a two-way radio
conference for The Department of Postgraduate Medicine. Albany exerted upon the nerve or vascular structures.
Medical College. on April 13 and 14, 1977. Postural improvement, corrective exercises, and
t From the Amsterdam Memorial Hospital. Upper Market Street, certain activities of daily living procedures con-
Amsterdam. New York 1201 0.
f Administrative Physical Therapist. tribute to this compression release.
89
90 SMITH JOSPT Vol. 1 , No. 2
EXAMINATION four maneuvers and the author's maneuvers are

also performed on the unaffected side and the
All therapy is preceded by a clarifying exami- results compared. The author prefers to test the
nation of the patient by the physical thera- uninvolved side first. The various diagnostic ma-
pist.~.2.4. 7-10 A thorough history is taken fol- neuvers are helpful, but not infallible. To help
lowed by a physical examination that includes differentiate between a neurovascular compres-
the following tests: 1) Adson's maneuver: for sion syndrome of the shoulder girdle and a cer-
compression occurring in the interscalene vical lesion, the following maneuvers are per-
space. 2) Costoclavicular maneuver: for com- formed to eliminate, diminish, or change the
pression occurring in the costoclavicular space. patient's symptoms: 1) if compression within the
3) Hyperextension maneuver: for compression shoulder girdle is suspected, passively elevate
occurring from the pectoralis minor tendon, sub- the shoulder girdle in the sitting position for 20-
clavius muscle and/or costocoracoid membrane 30 seconds; and 2) if cervical radiculopathy is
or ligament. 4 ) Hyperabduction maneuver: same suspected, perform positional distraction in con-
as the hyperextension maneuver, but considered junction with manual traction. Possibly 30-35
pounds of traction may be required. If both of
by some to be less accurate in incriminating the

upper thoracic musculature due to the backward these maneuvers are negative (no relief of symp-
movement of the clavicle upon upper extremity toms or change, e.g., numbness changing to
elevation. pins and needles-release phenomena) and a
The examination should also include sensory thorough examination of the cervical and upper
and manual muscle testing, differential palpa- thoracic spine has been completed, an exami-
tion, check for muscle wasting, notation of upper nation is performed for an articular or periar-
extremity temperature, color, or presence of ticular disorder of the shoulder girdle and distal
edema, oscillometric studies (if indicated), ob- joints. Cyriax' method of soft tissue diagnosis is
servation of breathing pattern, examination for most helpful in determining the existence of spe-
postural defects, musculoskeletal deformity, cific articular and periarticular lesion^.^ The re-
tropic changes, release and compression phe- sults of the referring physician's examination can
nomena, carpal-tunnel syndrome, articular and also be useful diagnostic information (e.g., roent-
periarticular disorders of the affected upper ex- genograms, electromyography and nerve con-
tremity and shoulder girdle, shoulder-hand syn- duction studies, plethysmograms, myelograms,
drome, and a cervical and upper thoracic spine auscultation, etc.).

examination (foramina1 compression test, mobil-
ity, etc.). The author has also found the following TREATMENT MANAGEMENT
maneuvers diagnostically useful in eliciting the
The physical therapy approach to the treat-
patient's symptoms and/or signs: the patient is
placed in a sitting position. With the arm pas- ment of the TOS consists of three aspects of
sively supported in 80-90 degrees of shoulder management.
abduction and elbow flexion with the forearm Posture
parallel to the floor, the medial one-half of the
clavicle is passively depressed in the caudal The first aspect is correction of postural faults
direction. Only a moderate amount of pressure and poor body mechanics that may be causing
is exerted. The position is held for 15-20 sec- or contributing to neurovascular compression or
onds. The maneuver should also be performed irritation. For example, a common postural fault
with the patient taking and holding a deep that can aggrevate this condition is the sagging
breath. This test is designed to eliminate or min- or dropping of the shoulders; in other words, the
imize the stress placed upon the structures of round shouldered, slouched position. A forward
the shoulder joint and cervical spine during the head can indicate excessive tension in the sca-
test maneuver. Va:;ations of this maneuver can lene muscles. The patient must develop a greater
be performed, e.g., depressing the clavicle first awareness of his corrected posture. Initially, a
followed by the passive movement of the arm new postural attitude is frequently uncomforta-
into the test position; however, the examiner ble. Constant reminders and encouragement by
must first rule out a shoulder lesion as the pos- members of the family, therapist, and physician
sible cause of the patient's symptom^.^ The first are essential.
JOSPT Fall 1 9 79 THORACIC OUTLET SYNDROME 91
Orthopaedic Manual Therapy of the scalene muscles is an important prelimi-

nary step to increasing the mobility of the 1st
The second aspect of the treatment is ortho- and 2nd ribs (Fig. 2). Excessive tension in the
paedic manual therapy. The manual therapy in- scalene muscles can result in elevation of the
creases the mobility of the shoulder girdle and 1st rib, thus reducing the size of the costocla-
the 1st and 2nd ribs on the affected side. The vicular space. If the nerve compression is occur-
shoulder girdle and the 1st and 2nd ribs on the ring in the interscalene triangle, the patient's
unaffected side also are treated in order to make symptoms can be diminished at times by restor-
postural adjustments easier from the kinesthetic ing or improving the elasticity of the scalene
standpoint. Greater attention, of course, is given muscles, especially if they have been in a guard-
to the affected side. The manual therapy consists ing position for an extended period of time. Cau-
of joint mobilization, soft tissue stretching and tion is to be demonstrated in performing this
articulation, massage, and mobilization exer- procedure. The muscle stretching should always
cises. The anatomical structures involved are the be done in a slow, gradual manner. Stretching
sternoclavicular and acromioclavicular joints, of the scalene muscles should not be performed
scalene musculature, 1st and 2nd ribs, shoulder if there is an irritation of the brachial plexus in
girdle musculature, and cervical and upper tho- which traction on the plexus causes pain. A
racic spine and musculature. The mobilization is gentle kneading massage of the scalene muscles
comprised of the following seven steps. can also be done if there is no brachial plexus or
The first step is mobilization of the sternocla- nerve root irritation. If necessary, deep sustained
vicular joint.' This passive movement is an an- pressure over the belly of the muscles can be
teroposterior shear of the clavicle upon the ster- used to induce relaxation. The pectoral muscles
num in a somewhat vertical plane (Fig. 1). This are the second group of muscles to be stretched
procedure is followed by mobilization of the ac- (Figs. 3 and 4).
romioclavicular joint that is an anteroposterior The third step is scapula mobilization.'. ". l 2
shear of the clavicle upon the acromion in a This includes dorsal (away from the thorax),
somewhat horizontal plane. Caution must be cephalad, caudal, medial, lateral, and rotary
shown not to create laxity at these joints by movements of the scapula (Figs. 5 and 6).
excessive articulation. The fourth step is 1st and 2nd rib articulation
The second step is passive stretching of the with the emphasis upon the 1st rib (Fig. 7)."* l 3
scalene and pectoral muscles, and if indicated, Figure 7 is posterior articulation with the cervical
massage of the scalene muscles.73" Stretching column stabilized through facet opposition and
Fig. 1. Mobilization of the sternoclavicular joint. The therapist is grasping the medial third of the clavicle.
Fig. 2. Stretching of the scalene muscles. The Therapist's right hand is stabilizing the patient's shoulder.
Fig. 3. Stretching of the pectoral muscles and fascia. Some counterpressure is applied by the therapist's right hand on the
belly of the pectoralis major.
ligamentous tension locking. Pressure is di- musculature. A deep kneading massage is given
rected caudally and centrally over the angle of to those muscles that have lost their elasticity
the rib. Springing of the 1st and 2nd ribs is also due to muscle guarding and/or emotional ten-
performed which creates a separational stress sion. The petrissage is preceded and followed
at the costovertebral joints (Fig. 8). The posterior by an effleurage to improve venous and lym-
articulation is followed by anterior articulation of phatic circulation and to relax the patient. With
the 1st and 2nd ribs with the pressure directed the more emotionally sensitive patient, local
caudally against the sternocostal insertion of the heating may precede the massage (e.g., infrared
Ist rib and the upper border of the 2nd rib (Fig. radiation or the use of a hydrocollator pack).
9). The sixth step is passive scapula-thoracic flex-
The fifth step is massage of the shoulder girdle ibility exercises (Figs. 10 and 11)." Complete
JOSPT Fall 1979 THORACIC OUTLET SYNDROME
Fig. 4. An exercise to stretch tight pectoral muscles and fascia. The patient faces a corner of a wall and leans his body toward
the corner without moving his hands or forearms on the wall.
Fig. 5 . Mobilization of the scapula in the cephalad, caudal, medial, and lateral directions.
relaxation of the patient during these passive The seventh step may or may not be neces-
movements is essential. sary. This last step is the treatment of the cervical
Mobilization techniques other than those de- lesion, if indicated (e.g., apophyseal joint dys-
scribed may be used to accomplish the treatment function, disc protrusion, spondylosis, etc.). A
objective. The author varies the technique ac- cervical lesion(s) could irritate the nerve supply
cording to the individual needs of the patient. to the scalene, subclavius, and pectoralis major
During certain mobilization procedures, it is not and minor muscles, resulting in increased mus-
unusual to evoke the patient's symptoms, espe- cle tension, loss of muscle elasticity, possible
cially in the beginning of the treatment program. shortening of the soft tissue, and reduction in
However, one must stop short of reproducing a size of the interscalene or costoclavicular space.
pain symptom. As a result, the TOS signs and symptoms could
be secondary to the cervical lesion. The patient's use of heat (or possibly cold), adjustive or pos-
signs and symptoms could also be caused by tional distraction, mechanical or manual traction,
pathology involving both areas. Physical therapy soft tissue stretching and articulation, spinal joint
treatment to the cervical spine would include the mobilization, and/or massage. The type of cer-
vical lesion will dictate the treatment protocol to
follow, which has been determined through a
thorough clarifying examination.
With the emotionally sensitive patient, the phy-
sician prescribed use of muscle relaxants or
tranquilizers to reduce nervous and muscular
tension is sometimes helpful during the period of
time the patient is receiving his manual therapy
treatments. The patient should be instructed to
take his medication approximately one hour be-
fore receiving his treatment.
Home Program
The third aspect of therapy management is the

home program. Exercises for specific shoulder
girdle muscles and/or the upper trunk (and pos-
sibly the lower trunk) are given only when there
is evidence of a musculoskeletal defect due to a
postural fault, muscle weakness, or muscle tight-

ness. However, all patients are instructed in a
shoulder girdle circumduction exercise (in oth-
erwords, "rolling" the shoulders in as large a
circle as possible). Instruction in "shoulder
shrugs" as a primary exercise is not given. Very
seldom do you find weakness in the trapezius
and levator scapulae muscles. By exercising the
scapular elevators, you improve the total effi-
ciency of these muscles, not only their ability to

Fig. 6. Rotary movement of the scapula upon the chest wall. contract, but also their ability to relax. Exercise
Fig. 7 . Posterior articulation of the 1st and 2nd ribs on the right side with the cervical column locked. The therapist's leff hand
is maintaining the patient's cervical spine in leff side flexion and right rotation. (Each rib is done separately.)
JOSPT Fall 19 79 THORACIC OUTLET SYNDROME 95
can contribute to neurovascular compression.
The patient should always maintain the normal
thoracic curve (in otherwords, stand or sit tall);
however, he must not overcompensate by keep-
ing his upper body tense with his scapulae hy-
peradducted. If the patient's resting posture ex-
hibits a forward (or "poked") head, he should be
shown how to maintain correct posture by keep-
ing his chin tucked in.
2) The patient should not carry heavy objects
(e.g., a heavy shopping bag) in the hand (or arm)
or slung over the shoulder on the affected side.
If carrying a heavy object on the involved side is
unavoidable, he should keep his shoulder ele-
vated (shrugged) while carrying the object. The
patient should also avoid physically stressful
tasks that require pulling, pushing, or lifting with

the affected arm.
3) Modification of sleeping habits is indicated
if there is night discomfort: If the patient's con-
dition is aggravated while sleeping, instruct him
to change sides of the bed with his spouse. This
arrangement may alter his sleeping posture and

provide symptomatic relief. If shoulder abduction
beyond 90 degrees aggrevates his condition,
gauze tied to the patient's wrist and attached to
the foot of the bed is sometimes helpful (allowing
arm movement as hiah - as the chest)- or ~. i n n i n- a
Fig. 8. Springing of the 1st and 2nd ribs creating a separa-
tional stress at the costovertebral joints. (Each rib is done
the sleeve of the pajama arm to the pajama leg.
separately.) The patient should avoid sleeping on the af-
fected side and in the prone-lying position. With
conditions a muscle to relax more completely; the head on a pillow (especially a thick pillow),
therefore, at rest, the position of the clavicle in the cervical spine in the prone position is placed
relation to the 1st rib is not altered by the shoul- in forced rotation and hyperextension. If the pa-
der shrug e ~ e r c i s e .Consequently,
~ the costo- tient's bed pillow is foam rubber, he should re-
clavicular space is not increased in size. The place it with a down-filled pillow.
scapulae elevators are incorporated into the 4 ) If indicated and if possible, the patient is to
shoulder circumduction exercise. modify occupational postural habits and body
To reiterate, the treatment objective is to 1) mechanics which precipitate or exacerbate his
enhance the overall mobility of the shoulder gir- signs and symptoms.
dle by restoring any loss of accessory joint 5) For female patients, bra straps should not
movement with passive mobilization techniques, be tight and should be stretch straps. For the
2) improve muscle efficiency with active exer- woman with pendulous breasts, a strapless long-
cises and massage, and 3) change postural line bra may help diminish the patient's signs
habits and body mechanics that exacerbate the and symptoms.
patient's signs and symptoms. 6) The patient is to avoid physical activities
Exercise and posture instructions at home and that result in hard or rapid breathing. These
at work are essential to the success of this activities may recruit the accessory breathing
program. The patient should be given instruc- muscles (the scalene) which elevate the 1 st rib.
tions related to occupational, recreational, and 7) The patient should try to avoid emotionally
sleeping habits which include the following: stressful situations. Muscular tension in the
1) When working or relaxing, the patient shoulder girdle musculature can contribute to a
should avoid the round shouldered, slouched worsening of the patient's symptomatology.
position. Sagging or drooping of the shoulders 8) The patient should not undertake strenuous
Fig. 9. Anterior articulation of the 1st and 2nd ribs. (Each rib is done separately.)
Fig. 1 0. Scapula-thoracic flexibility exercise that consists of a passive circular movement.
physical tasks without adequate rest periods. arm on a chair armrest or pillow. The arm should
Excessive fatigue from a work or recreational be positioned below shoulder level.
activity may result in poor posture and an aggra- 12) If the patient has an acute episode of his
vation of the condition. symptoms, instruct him to pull his shoulders up
9) If the automobile shoulder strap crosses into the shoulder shrug position as far as possi-
the clavicle on the affected side, the patient must ble and hold them in this position for 30-60
not draw the strap too snugly. seconds. The head should be kept in a neutral
10) The patient should avoid any activity that position (facing straight forward), not tilted back-
results in backward bending of the head or ele- wards or pushed forward. If necessary, instruct
vation of the affected arm over the head. the patient to a) lie in the back-lying position with
11) Whenever the patient is relaxing in the his head placed on 3-4 folded towels and side
sitting position, instruct him to rest the affected bent tdward the affected side; b) with the arms
JOSPT Fall 1979 THORACIC OUTLET SYNDROME 97
Fig. 1 1 . Scapula-thoracic flexibility exercise that is also a ~ a s s i v ecircular movement.
slightly abducted and the elbows slightly flexed, into the treatment program after 5-1 0 sessions.
place one folded towel under the affected upper The length of each treatment session will vary
arm and 3-4 folded towels under the lower fore- according to the therapist's data base and ree-
arm and hand; c ) partially shrug both shoulders; valuation of the patient. Examples of treatment
and d) relax completely. At times, having the variability include patients that require more soft
patient rest his hands on his upper chest or tissue treatment than others and cases in which
abdomen provides greater symptomatic relief. A the TOS exists bilaterally. The treatment time will
bed pillow under the knees is also helpful. vary from %-I hour. Upon completion of the
13) If an acute episode occurs in public, in- treatment program (8-1 4 treatments), the ther-
struct the patient to roll his shoulders a few apist again performs the previously mentioned
times, straighten his upper (thoracic) spine, and test maneuvers for the TOS and compares re-
place the hand of the affected arm in his coat sults.
pocket or the front pocket of his trousers (or
slacks) and relax the arm. Case Study
Frequency and Duration of Treatment A 36-year-old woman was seen in our facility
complaining of a 3 year history of numbness
The patient should be seen daily for the first (daytime and nocturnal) preceded by tingling in
week and then three times per week for the next all five digits of the right hand, a feeling of
1-3 weeks for a maximum of 8-1 4 treatments. "pressure" in the right forearm, and muscle
If you do not achieve significant results after 12- soreness in the right upper extremity with activ-
14 treatments, physical therapy is not the answer ity. The patient also complained of coolness in
in that particular case of TOS. A neurological the tips of all digits and episodes of swelling in
and/or surgical consultation should then be con- the hand. She found it difficult to pursue her
sidered. If it is diagnostically confirmed that the profession as a beautician.
patient's signs and symptoms are strictly the On physical examination Adson's maneuver
result of the TOS and not secondary to a cervical was negative. The costoclavicular maneuver
lesion, all treatment is directed to the shoulder elicited paraesthesia in all five digits and mark-
girdle and the 1st and 2nd ribs. However, if a edly diminished the radial pulse. Upon hyperex-
cervical lesion is contributing to the patient's tension and hyperabduction, the paraesthesia
symptomatology but to a lesser degree (in oth- was again evoked but was less pronounced than
erwords, more than one lesion exists), treatment in the costoclavicular test and the radial pulse
of the cervical condition should be incorporated was only slightly dampened. The author's ma-
neuver elicited paraesthesia in the tips of all diminished. Arm soreness improved. The cold-
digits, especially the little finger, and a "pulling" ness of all digits was infrequently experienced.
sensation in the upper arm. The hand no longer became edematous. Al-
Testing of the opposite side evoked identical though the patient was not completely asymp-
symptoms, but the paraesthesia was less intense tomatic, she was quite satisfied with the therapy
and less area was involved. There was a loss of results. Her residual symptomatology was not a
mobility in the shoulder girdle bilaterally and significant discomfort factor. The patient has
impaired accessory movement in the sternocla- reported no regression in her condition since the
vicular and acromioclavicular joints on the right termination of her therapy 8 months ago.
side. The shoulders were somewhat rounded.
Muscle strength, skin temperature, and color CONCLUSION
were uneffected. Examination of the cervical and
thoracic spine and the shoulder, elbow, wrist, Our preliminary results have convinced us that
and finger joints revealed no evidence of an this particular approach to the treatment of the
articular or periarticular lesion. There were no TOS is an effective method of managing this
musculoskeletal deformities. Other tests men- musculoskeletal condition (Table 1). Fifteen of
tioned in the text were negative. the 20 patients reported a significant decrease
These findings and the patient's history sug- in the number of episodes, the severity, and the
gested compression occurring primarily in the extent (area involved) of the paraesthesia, numb-
costoclavicular space involving the lower cords ness, and/or pain. A follow-up study was done
of the brachial plexus and the subclavian vein. of these 15 patients. The time that these patients
The patient was given the protocol of treatment were off the treatment program averaged 9%
as described. After 1 0 therapy sessions, during months, ranging from 1 month to 2 years. Eleven
which time the patient continued to work, she of these 15 patients reported no recurrence or
reported significant improvement in her overall regression in their condition since recieving their
symptomatology. The patient noted only occa- initial therapy treatments. The remaining four
sional episodes of minimal paraesthesia. The patients of this group reported slight regression;
sensation of pressure in the forearm was greatly however, further therapy was not required.
TABLE 1
Physical Therapy Management of the Thoracic Outlet Syndrome: Results
Patient Sex No. of treatments Considerable im- Moderate improve- Temporary im-
provementc NO improvement
provement" mentb
1 F 8 X
2 F 7 X
3 M 7 X
4 F 4 Xd
5 F 6 Xd
6 F 8
7 M 6 Xd
8 M 14 X
9 M 8
10 M 6 Xd
11 F 6
12 M 7
13 F 3
14 M 12 X
15 M 9
16 F 7 X
17 F 7
18 F 1 X
19 M 9 X
20 F 10 X
a Paraesthesia, numbness, and/or pain: very few episodes, less severe, and less area involved.
Paraesthesia, numbness, and/or pain: occasional episodes and less severe.
Some relief of symptoms of short duration following each treatment session. No significant or lasting results.
Completely asymptomatic.
Surgery: 1st rib resection.
JOSPT Fall 1979 THORACIC OUTLET SYNDROME 99

The author thanks Dr. Gustav E. Kappler Ill for stimulating the 7. Mennell JMcM: Musculoskeletal Pain. Boston. Little. Brown, and
author's interest in finding and developing a more effective approach Company, 1976, pp 209-21 1
to the conservative management of the TOS. 8. Mennell JMcM: Joint Pain. Boston, Little, Brown, and Company,
1964, PP 1-31, 87-90
9. Beetham WP Jr. Polley HF. Slocumb CH. Weaver WF: Physical

REFERENCES: Examination of the Joints. Philadelphia, WB Saunders Company.
1965. pp 1-1 21
1. Lord JW Rosati LM: Thoracic outlet syndromes. Clinical Sympo- 10. Hoppenfeld, S: Physical Examination of the Spine and Extremi-
sia. Summit, New Jersey. ClBA Pharamaceutical Company, ties. New York. Appleton-Century-Crofts. 1976. pp 1-1 32
1971, pp 1-32 11. Stoddard. A: Manual of Osteopathic Technique. London, Hutch-
2. Roos DB: Congenital anomalies associated with thoracic outlet inson Medical Publications. 1972, pp 99. 120-1 23. 171. 172.
syndrome. Am J Surg. 132:12. 1976 174, 175
3. Urschel HC. Paulson DL, McNamara JJ: Thoracic outlet syn- 12. Kaltenborn, FM: Manual Therapy for the Extremity Joints. Oslo;
drome. Ann Thorac Surg. 6.1 , 1968 Olaf Norlis Bokhandel, 1974, pp 86, 87
4. Cyriax J: Textbook of Orthopedic Medicine. Vol 1. Sixth Edition, 13. Maitland GD: Peripheral Manipulation. London. Butterworth and
London. HK Lewis and Company. 1976. pp 61 -98. 169-1 79 Company, 1974, pp 148, 149
5. Cailliet R: Neck and Arm Pain. Philadelphia, FA Davis Company. 14. Dale AW, Lewis MR: Management of Thoracic Outlet Syndrome.
1964, pp 92-96 Ann Surg, 181:5, 1975, pp 575-585
6. Stoddard A: Manual of Osteopathic Practice. New York, Harper 15. Cailliet R: Shoulder Pain. Philadelphia, FA Davis Company. 1966,
and Row, 1969, pp 21 4-21 6 pp 101-106

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01 96-601 1 /79/0102-0089$02.

The Thoracic Outlet Syndrome:

exercises, improved body mechanics, and other procedures relating to the

EXAMINATION four maneuvers and the author's maneuvers are

by some to be less accurate in incriminating the

drome, and a cervical and upper thoracic spine auscultation, etc.).

Orthopaedic Manual Therapy of the scalene muscles is an important prelimi-

The third aspect of therapy management is the

postural fault, muscle weakness, or muscle tight-

ciency of these muscles, not only their ability to

tasks that require pulling, pushing, or lifting with

arrangement may alter his sleeping posture and

Fig. 1 0. Scapula-thoracic flexibility exercise that consists of a passive circular movement.

Fig. 1 1 . Scapula-thoracic flexibility exercise that is also a ~ a s s i v ecircular movement.

JOSPT Fall 1979 THORACIC OUTLET SYNDROME 99

9. Beetham WP Jr. Polley HF. Slocumb CH. Weaver WF: Physical

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