THORACIC OUTLET SYNDROME

Signs and Symptoms

The signs and symptoms of thoracic outlet syndrome are neurologic or vascular, or both, and include upper extremity pain, hyperesthesia, hypoesthesia, paresthesia, and weakness. Onset is gradual, though symptoms can be exacerbated by prolonged positioning of the arm overhead. Distal edema (swelling) indicates compromise of venous return and is cause for immediate medical attention.

Assessment

When the patient is positioned in a way that reproduces symptoms, the specific source of impingement can be identified. The scalenus anticus or Adson maneuver is positive if the radial pulse is diminished or obliterated and symptoms are reproduced when the patient holds a deep breath with the neck extended and rotated toward the side of involvement while the arm is abducted. Impingement by the first rib and clavicle is reproduced by scapular depression and retraction. The hyperabduction test, performed by combined hyperflexion and hyperabduction of the arm implicates the pectoralis minor syndrome. X-rays may reveal bony abnormalities responsible for cervical rib syndrome.

Treatment

A 12 to 16 week trial of conservative treatment is aimed at avoiding surgical intervention by enlargement of passageways through which the neurovascular bundle passes. The goals of treatment are to decrease muscle spasm; improve posture; increase anterior thoracic muscle flexibility; increase posterior thoracic muscle strength; and increase scapular, costovertebral, acromioclavicular, and sternoclavicular mobility.

Acute State

A.Support of the extremity

1.When ambulating, use sling.

2.When sitting, support the extremity on the arm of a chair or table.

B.Range of Motion

1.Carry shoulder through a full painless range of motion several times daily to prevent soft tissue contracture.

C.Heat, both superficial and deep, for relief of pain and spasm.

1.Hot packs;

2.Ultrasound, alone or in combination with electrical stimulation;

3.Electrical stimulation. A sinusoidal current is the one tolerated best.

D.Light sedative massage, with or without ice.

E.Intermittent cervical traction -- with the patient in a horizontal position.

As pain lessens an exercise program is initiated.

A.Active mobilization exercises, if there is limitation of shoulder range of motion.

B.Codman's exercises or pendulum exercises performed three times daily with the patient using a 1 kg weight.

C.Correction of posture. AN important procedure in treatment.

D.Specific shoulder girdle exercises.

1.Deep-breathing exercises. Hold for count of 5. Ten repetitions.

2.Neck range of motion and isometric exercises.

3.Shoulder exercises.

4.Upper shrugging exercises. Slowly increasing holding weights in hands. Ten repetitions.

5.The following exercises may be done daily after application of moist heat to the upper back and neck: Passive pectoral stretching by leaning into a corner, shoulders horizontally abducted; hold for 30 seconds, repeat three times. Cervical spine sidebending left and right done passively by therapist with athlete supine; hold for 30 seconds, repeat three times. Contract-relax-contract anterior chest stretching by shoulder horizontal abduction; five isometric contractions for 8 seconds each.

E.Special consideration

1.The patient must be cautioned to carry out the exercises slowly and hold for a count of five so the effect of both isotonic and isometric exercises can be achieved. Should be done three times a day, three sets for ten repetitions.

2.The patient should be aware that the first two to seven days are often quite painful, but that thereafter, the symptoms should lessen.

3.Muscle relaxants and/or anti-inflammatory medications as directed by the physician.

4.No working with the involved arm overhead.

Recommended Regimen

Strengthening. Each of the following exercises is done for two to four sets of ten daily: Scapular retraction done standing, holding two percent body weight (BW) in each hand. Scapular retraction with elevation, holding two percent BW in each hand. Chin and chest raise done prone with hands clasped behind the back. Alter-nating single arm raise done prone with arms outstretched overhead.

Activities. Avoid all activities and postures that require repetitive or prolonged shoulder abduction above the horizontal level.

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