Thoracic Outlet Syndrome: An Overview of Anatomy, Diagnosis and Treatment

Thoracic Outlet Syndrome: An Overview of Anatomy, Diagnosis and Treatment

Developed by: Blair Burnette, SPT

Welcome to my DPT Capstone Site! I am grateful that you have taken the time to take to stop by and hope that the information presented will provide you will new perspective and become a useful tool for your clinical practice.

My Personal Connection to the Topic

I would like to share a little additional information pertaining to exactly why I chose to research and present on this topic.  I began my physical therapy education in the fall of 2012; however, a few months into the program I started to experience a tingling sensation in my 5^th digit.  Initially, I just shrugged it off assuming that it was no big deal.  By October 2012, I was experiencing the numbness constantly while beginning to have trouble dropping things and having sharp shooting pain while studying.  I consulted with a few faculty members regarding my condition and tried various splinting and taping techniques to no avail. Due to the limited success of these interventions, I opted to consult an upper extremity specialist in the beginning of 2013. X-rays of my wrist and hand came back negative for fracture, MRI imaging revealed no cysts or other soft tissue abnormalities and nerve conduction velocities revealed no significant deviation from normal conduction rates in the ulnar nerve.  After all of that imaging, I was prescribed a night splint and instructed to follow-up with the physician in one month.  During the course of that month, our class studied thoracic outlet syndrome and learned the special tests associated with its diagnosis. As we practiced the tests, I displayed a positive test result and experienced the same pain I had been having for months of nearly every test.  At my follow up appointment, I shared these finding with my physician and he agreed that those results in conjunction with my symptoms made sense for thoracic outlet syndrome.  My night splint was discontinued and I was referred to physical therapy for a variety of stretching techniques, exercises and education regarding thoracic outlet syndrome.  Ever since that point in time, I have been able to effectively manage my symptoms and have had no residual problems from the condition. Based on this experience, I was determined that there had to be a more efficient method to diagnose and treat this condition.  This project is an attempt to bring more light to the topic of thoracic outlet syndrome by helping clinicians and future clinicians to be more aware of the causes and potential presentation of this condition.

Overview

Thoracic Outlet Syndrome (TOS) is a condition that involves the compression of the neurovascular bundle known as the brachial plexus as it leaves the spine and travels out to the upper extremity.  The true cause and existence of TOS has been a source of debate in the medical community; resulting in a dearth of evidence regarding diagnosis and treatment of the condition. Recent medical and technological advances, including diagnostic imaging, have shifted the opinion of the medical community in favor of the existence of TOS.  However, the long-standing divide has created significant gaps in research and knowledge regarding the topic. This lack of consistency led to the development of many tests and measures to diagnose the condition. These tests can range in cost from virtually no cost to thousands of dollars. With healthcare expenditure at an all-time high it is critical that medical professionals have adequate information to provide the highest quality care at the lowest cost to their patients.  For this reason, it is essential that entry level physical therapy students have a strong foundational knowledge of thoracic outlet syndrome as well as the psychometric properties, and benefits and limitations of all of the tests available. The purpose of this project is to provide an initial introduction to the anatomy of the thoracic outlet region, potential causes of the condition, typical symptom presentation, tests for diagnosing the condition including their usefulness and target region, as well as potential conservative and surgical treatment options.

Project Development 

In addition to my personal experience, I developed the plan for this project based on work I did for the Evidence Based Practice II course as well as the Advanced Orthopedic Assessment course.  In the EBP II course, I developed a PICO question pertaining to whether shoulder special tests (Adson’s, Costoclavicular, Hyperabduction, Allen’s and Roo’s) where more effective in diagnosing thoracic outlet syndrome than nerve conduction velocities in patients presenting with symptoms of the thoracic spine. This question became the foundation for the development of Critically Appraised Topic on this issue.  The information gathered through this CAT prompted me to conduct additional research into diagnosis and treatment of thoracic outlet syndrome.  I utilized this information to develop my final project for the Advanced Orthopedics course.  The products of both of these projects provided a strong foundation for the development of this Capstone presentation.  However, prior to developing this presentation, I conducted additional research pertaining to the specific anatomy of the thoracic outlet region, causes of thoracic outlet syndrome and more detailed information regarding the management of this condition.

The Project

I developed a PowerPoint Presentation to present to the 30 first year eDPT students at the University of North Carolina-Chapel Hill during their Musculoskeletal I course, as well as their third year teaching assistant students and the course’s lead faculty member.  Unfortunately, the presentation was cancelled due to a snow storm on the intended presentation date.  For this reason, I developed a video file of the PowerPoint with my narration that can be accessed here.  I also asked the first year students to complete an evaluation form after viewing the presentation.  A compilation of their responses is included here.

Based on the feedback of my adviser and the first year students, I added an additional slide of stretches for the pectoralis minor region of the thoracic outlet.  The updated PowerPoint with this information is linked here.

Acknowledgements

I would like to give a huge heart-felt thank you to my committee members Mike McMorris and Jennifer Cooke for their advice and assistance in developing the presentation.  Additional thanks go out to my capstone project adviser Mike Gross for sharing his expertise and experience to help me develop the most effective project.  Finally, I would like to thank both my third year classmates for their support and encouragement for the project, as well as the first year students for their receptiveness and enthusiasm for the presentation.

References

1. Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. Neurologist. 2008;14(6):365-73.
2. Bayford T. THORACIC OUTLET SYNDROME: AN OVERVIEW OF DIAGNOSIS AND TREATMENT. Sportex Medicine[serial online]. April 2010;(44):13-17. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed January 21, 2015.
3. Gross, M (2012). Thoracic Outlet Compression Syndrome (lecture). Accessed November 18, 2014.
4. Freischlag J, Orion K. Understanding thoracic outlet syndrome. Scientifica (Cairo). 2014;2014:248163.
5. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders, Physical Therapy Principles and Methods. Lippincott Williams & Wilkins; 2006.
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7. Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg. 2002;36(1):51-6.
8. Gillard J, Pérez-cousin M, Hachulla E, et al. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint Bone Spine. 2001;68(5):416-24.
9. Cook C, Hegedus EJ. Orthopedic Physical Examination Tests, An Evidence-Based Approach. Prentice Hall; 2011.
10. McMorris, M (2012). Shoulder Special Tests: Technique Sheet (handout). Accessed February 3, 2015.
11. Demirbag D, Unlu E, Ozdemir F, et al. The relationship between magnetic resonance imaging findings and postural maneuver and physical examination tests in patients with thoracic outlet syndrome: results of a double-blind, controlled study. Arch Phys Med Rehabil. 2007;88(7):844-51.
12. Povlsen B, Belzberg A, Hansson T, Dorsi M. Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev. 2010;(1):CD007218.
13. Nichols AW. Diagnosis and management of thoracic outlet syndrome. Curr Sports Med Rep. 2009;8(5):240-9.
14. Magee DJ. Orthopedic Physical Assessment. Elsevier Health Sciences; 2008.