thoracic outlet syndrome; one of the disorder affecting shoulder joint and neck movements due to limitation and pain. this slideshow describes about; the definition, types, causes and physiotherapy management for the same.

1. Thoracic Outlet Syndrome:
By: Radhika Chintamani
Introduction: Thoracic outlet syndrome is a group of disorders that occur when blood vessels or nerves in
the space between your collar bone and your first rib (thoracic outlet) are compressed. This can cause
pain in your shoulders and neck and numbness in your fingers.
There are three main types:
1. The neurogenic type: is the most common and presents with pain, weakness, and occasionally
loss of muscle at the base of the thumb.[1][2]
2. The venous type results in swelling, pain, and possibly a bluish coloration of the arm.
3. The arterial type results in pain, coldness, and paleness of the arm.[2]
Anatomy: Anatomically these syndrome can be classified into 3 types depending on the area where the
compression occurs:
1. 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 brachial plexus and the subclavian artery pass
through this space.
2. 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 brachial plexus crosses this costoclavicular
region and then further enters the subcoracoïd space. Just distal to the insterscalene 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.
3. 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 minor can lead to a narrowing of
this last space and therefore compression of the neurovascular structures during hyperabduction.
Epidemiology:
Evidence: Study stated that TOS affects woman 3-4times than 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.
Evidence: A study stated in conclusion that among 20 subjects with TOS, 15 had brachial plexus injury.
(95-98%); the other 2-5% affecting vascular structures, such as the subclavian artery and vein.
Causes:
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.
TOS may result from trauma, repetitive arm movements, tumors, pregnancy, or anatomical
variations such as a cervical rib. The diagnosis may be supported by nerve conduction

2. studies and medical imaging. Other conditions that can produce similar symptoms include rotator cuff
tear, cervical disc disorders, fibromyalgia, multiple sclerosis, and complex regional pain syndrome.[1]
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 [2],
and functionally acquired anatomical changes [3]. 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,…).
Congenital factors Acquired Muscular Systemic
Cervical rib
Prolonged transverse
process
Anomalous muscles
Fibrous anomalies
(transversocostal,
costocostal)
Abnormalities of the
insertion of the scalene
muscles [4]
Fibrous muscular
bands[4]
Exostosis of the first rib
Cervicodorsal
scoliosis[11]
Congenital uni- or
bilateral elevated
scapula
Postural factors
Dropped shoulder
condition
Wrong work posture
Heavy mammaries
Trauma to clavicle or first
rib
Clavicle fracture
Rib fracture
Hyperextension neck
injury, whiplash
Repetitive stress injuries
Hypertrophy of the
scalene muscles
Decrease of the tone
of the trapezius,
levator scapulae,
rhomboids
Shortening of the
scalene muscles,
trapezius, levator
scapulae, pectoral
muscles
Pancoast’s Syndrome
Radiation induced
brachial plexopathy
Parsonage Turner
Syndrome [2][3]
There are conditions
that can coexist with
TOS, like:
carpal tunnel
syndrome
peripheral neuropathies
(like ulnar nerve
entrapment at the
elbow, shoulder
tendinitis and
impingement
syndrome)
fibromyalgia of the
shoulder and neck
muscles
cervical disc disease
(like cervical
spondylosis and
herniated cervical
disk)
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.
a. Pain anywhere between the neck, face and occipital region or into the chest, shoulder and upper
extremity.
b. Paresthesia in upper extremity: altered or absent sensation, weakness, fatigue, a feeling of
heaviness in the arm and hand.
c. The skin can also be blotchy or discolored.
d. A different temperature can also be observed.
e. 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.
f. 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. [24][2]

3. 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.
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.
Differential Diagnosis:
a. Complex regional pain syndrome (CRPS I or II).
b. Horner’s Syndrome
c. Raynaud’s disease
d. Cervical disease (especially discogenic)
e. Brachial plexus trauma
f. Systemic disorders: inflammatory disease, esophageal or cardiac disease
g. Upper extremity deep venous thrombosis (UEDVT), Paget-Schroetter syndrome
h. Rotator cuff pathology
i. Glenohumeral joint instability
j. Nerve root involvement
k. Malignancies (local tumours)
l. Chest pain, angina
m. Vasculitis
n. Sympathetic-mediated pain.
Outcome measures:
DASH (Disability of Arm Shoulder and Hand)
SPADI (Shoulder Pain And Disability Index)
NPRS (Numeric Pain Rating Scale)
McGill Pain Questionnaire[2]

4. Special tests:
 Elevated Arm Stress/ Roos test: the patient abducts arms at 90° and the therapist puts downwards
pressure on the scapula as the patient opens and closes the fingers. If the TOS symptoms are
reproduced within 90 seconds, the test is positive.
 Adson's: the patient is asked to rotate the head and elevate the chin toward the affected side. If the
radial pulse on the side is absent or decreased then the test is positive, showing the vascular
component of the neurovascular bundle is 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.
 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. (Hooper et. al.,
2010 & Brismee et. al., 2004)
 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. (Hooper et al., 2010)
 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 the neurogenic component of the neurovascular bundle is
compressed. [24]
 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". (http://www.physio-pedia.com/Neurodynamic_Assessment)
 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.

5. PT Rx for TOS:
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. Treatment is directed towards the specific stage of TOS:
Stage 1: Controlling stage:
Aim: 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 decrease as
time passes. [17] Level of evidence 2B
Also cervical traction in combination with a hot pack and light exercise may reduce pain and irritable
symptoms for some acute patients. Level of evidence 2B
Breathing technique: Encouraging diaphragmatic breathing will lessen the work load on already overused
or tight scalenes and can possibly reduce symptoms. [17] Level of evidence 2B
Stage 2: Treating stage:
Aim: is to directly address the tissues that create structural limitations of motion and compression.
Methods of Rx:
a. Massage.
b. Stretching of the pectoralis, lower trapezius and scalene muscles = These muscles close the thoracic
outlet
c. 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
d. Postural correction exercises
e. Relaxation of shortened muscles [36] Level of evidence 1A
f. Aerobic exercises in a daily home exercise program: [36] Level of evidence 1A, [38] Level of evidence
2B
1) 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.

6. 2) 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.
3) 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:
- 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.
4) Stretching exercises
• Taping: some patients with severe symptoms respond to additional taping, adhesive bandages or braces
that elevate or retract the shoulder girdle.[15] Level of evidence 1C, [36] Level of evidence 1A
• Manipulative treatment to mobilize the first rib
Could provoke irritation and pain symptoms in some patients [36] Level of evidence 1A
• Repositioning/mobilization of the shoulder girdle and pelvis joints: cervicothoracic, sternoclavicular,
acromionclavicular, and costotransverse joints [36] Level of evidence 1A, [17] Level of evidence 2B
• Glenohumeral mobilizations in end-range elevation with the elbow supported in extension [38] Level of
evidence 2B
A) 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).
B) 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.
C) 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. [17] Level of evidence 2B
First Rib Mobilization: Patient seated. Thin sheet strap positioned around first rib. Pull strap towards
opposite hip. Neck retracted, contralateral lateral flexion, and ipsilateral rotation. Ipsilateral head rotation
emphasizes scalene stretch. Contralateral rotation emphasizes rib mobilization.
Posterior Glenohumeral Glide with Arm Flexion: Patient supine. Mobilizing hand contacts proximal
humerus avoiding corocoid process. Force is directed posterolaterally (direction of thumb).
Anterior Glenohumeral Glide with Arm Scaption: Patient prone. Mobilizing hand contacts proximal
humerus avoiding acromion process. Force is anteromedially.
Inferior Glenohumeral Glide: Patient prone. Stabilizing hand holds proximal humerus. Mobilizing
hand contacts axillary border of scapula. Mobilize scapula in craniomedial direction along ribcage.
Post-Op Physical Therapy[3]
If a patient does require surgery, then physical therapy should follow immediately to prevent scar tissue
and return the patient to full function.