Thoracic Outlet Syndrome (TOS)
Online Course: Clinical Reasoning and Pathologies of the Thoracic Spine
Definition/Description
The term ‘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.[1] [2]
This condition has emerged as one of the most controversial topics in musculoskeletal medicine and rehabilitation[3]. This controversy extends to almost every aspect of the pathology including the definition, incidence, pathoanatomical contributions, diagnosis, and treatment.
The term ‘TOS’ does not specify the structure being compressed. Investigators namely identify 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).[1][2]
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 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.
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.[2][4][5]
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 [3], and functionally acquired anatomical changes[4]. 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,…).
Tos.jpg
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.[4][5][6] 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 that 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.[7] Fibrous bands are a more common cause of TOS than rib anomalies.
Congenital Factors:
Cervical rib[8][9][10]
Prolonged transverse process
Anomalous muscles
Fibrous anomalies (transversocostal, costocostal)
Abnormalities of the insertion of the scalene muscles[8]
Fibrous muscular bands[8]
Exostosis of the first rib
Cervicodorsal scoliosis[11]
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[8]
Wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine)
Heavy mammaries
Trauma[11]
Clavicle fracture[8]
Rib fracture[8]
Hyperextension neck injury, whiplash[9][12]
Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long hours)[12]
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
Characteristics/Clinical Presentation
Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of the 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 the 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 discoloured. 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.[13][14]
When the upper plexus (C5,6,7) is involved there is a 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 that 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.[3][5]
There are four categories of thoracic outlet syndrome and each presents with unique signs and symptoms (see Table 1). Typically TOS does not follow a dermatomal or myotomal pattern unless there is nerve root involvement, which will be important in determining your PT diagnosis and planning your treatment [3][4].
Arterial TOSVenous TOSTrue TOSDisputed Neurogenic TOS
Young adult with vigorous arm activity
Pain in the hand
Claudication
Pallor
Cold intolerance
Paresthesias
S/s usually appear spontaneously
Younger men with vigorous arm activity
Cyanosis
Feeling of heaviness
Paresthesia in fingers and hand (result of oedema)
Oedema of the arm
Hx of neck trauma
Pain, paresthesia, numbness, and/or weakness
Occipital headaches
S/s present-day and/or night
Loss of fine motor skills
Cold intolerance (possible Raynaud's phenomenon)
Objective weakness
Compressors*: s/s day>night
Hx of neck trauma
Pain, paresthesia, and "feeling" of weakness
Occipital headaches
Nocturnal paresthesias that often wake patient
Loss of fine motor skills
Cold intolerance (possible Raynaud's phenomenon)
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 overhead 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 paraesthesia 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 as an indicator of a favourable outcome and resolution of symptoms.
Differential Diagnosis
Due to its variability, TOS can be difficult to tease out from other pathologies with similar presentations. A thorough history and evaluation must be done to determine if the patient’s symptoms are truly TOS. The following pathologies are the common differential diagnosis for TOS[15][16] :
Carpal tunnel syndrome
De Quervain’s tenosynovitis
Lateral epicondylitis
Medial epicondylitis
Complex regional pain syndrome (CRPS I or II).
Horner’s Syndrome
Raynaud’s disease
Cervical disease (especially discogenic)
Brachial plexus trauma
Systemic disorders: inflammatory disease, oesophageal or cardiac disease
Upper extremity deep venous thrombosis (UEDVT), Paget-Schroetter syndrome
Rotator cuff pathology
Glenohumeral joint instability
Nerve root involvement
Shoulder Instability
Malignancies (local tumours)
Chest pain, angina
Vasculitis
Thoracic (T4) syndrome
Sympathetic-mediated pain
Systematic causes of brachial plexus pain include:
Pancoast’s Syndrome
Radiation induced brachial plexopathy
Parsonage Turner Syndrome[3][4]
There are conditions that can coexist with TOS. It is important to identify these conditions because they should be treated separately. These associated conditions include:
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)
Outcome Measures
DASH (Disability of Arm Shoulder and Hand)
SPADI (Shoulder Pain And Disability Index)
NPRS (Numeric Pain Rating Scale)
McGill Pain Questionnaire
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 be 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).[2][17] 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.[5][13]
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[18]
Make sure to take a 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[6][18]
Observation
Posture
Cyanosis
Oedema
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[3][6]
Elevated Arm Stress/ Roos test: the patient has arms at 90° abduction 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.[5]
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.[5]
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.[5]
Cyriax Release: the patient is seated or standing. The examiner stands behind the 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.[3]
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.[5]
Upper Limb Tension: These tests are designed to put stress on the neurological structures of the 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.
TestSensitivitySpecificityLR+LR-
Elevated Arm Stress52-84% 30-100% 1.2-5.2 0.4-0.53
Adson's79%74-100%3.290.28
Wright's
70-90%29-53%1.27-1.490.34-0.57
Cyriax ReleaseNT 77-97%NANA
Supraclavicular PressureNT 85-98%NANA
Costoclavicular ManeuverNT53-100%NANA
Upper Limb Tension90%38%1.5 0.3
Cervical Rotation Lateral Flexion100%NTNANA
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 the 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 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.[19][20][21] Surgical management of TOS should only be considered after conservative treatment has been proven ineffective.[22]
However, limb-threatening complications of vascular TOS have been indicated for surgical intervention.[23]
Surgery to treat thoracic outlet syndrome may be performed using several different approaches, including: transaxillary approach, supraclavicular approach and infraclavicular approach.[22]
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.[22][24][25]
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 he 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.[22][24][25]
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.[22][25]
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[23]. Terzis found that the supraclavicular approach to treatment to be an effective and precise surgical method[26]
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[23]
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 the infraclavicular approach is a safe and effective treatment for acute VTOS. They had no brachial plexus or phrenic nerve injuries.[24][27]
Angioplasty can then be used to treat those with venous stenosis[23]
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.[27]
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.[7][16][18]
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 conservative management and no treatment.[28] Conservative management includes physical therapy, which focuses mainly on patient education, pain control, range of motion, nerve gliding techniques, strengthening and stretching.[29]
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 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.[23]
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 for up to 30 minutes, observing for a symptom decrescendo as time passes.[23]
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 workload on already overused or tight scalenes and can possibly reduce symptoms.[23]
Scapula Settings and Control
In the treatment, you 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 [28]
Aerobic exercises in a daily home exercise program:[28][30]
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 straighten 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 is 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, acromioclavicular, and costotransverse joints [23][28]
Glenohumeral mobilizations in end-range elevation with the elbow supported in extension[30]
Taping: some patients with severe symptoms respond to additional taping, adhesive bandages or braces that elevate or retract the shoulder girdle.[18][28]
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[28]
Posterior Glenohumeral Glide with Arm Flexion:
The patient is supine. The mobilization 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.[23]
Firstribselfmob.jpg First Rib Mobilization: Patient seated. Thin sheet strap positioned around the first rib. Pull strap towards the opposite hip. Neck retracted, contralateral lateral flexion, and ipsilateral rotation. Ipsilateral head rotation emphasizes scalene stretch. Contralateral rotation emphasizes rib mobilization.
Posteriorghglidearmflex.jpg Posterior Glenohumeral Glide with Arm Flexion: Patient supine. Mobilizing hand contacts proximal humerus avoiding corocoid process. Force is directed posterolaterally (direction of thumb).
Antghglidearmscaption.JPG Anterior Glenohumeral Glide with Arm Scaption: Patient prone. Mobilizing hand contacts proximal humerus avoiding acromion process. Force is anteromedially.
Infghglide.JPG 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
If a patient does require surgery, then physical therapy should follow immediately to prevent scar tissue and return the patient to full function.
Key Research
Hooper T, Denton J, McGalliard M, Brismée J, Sizer P. Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. Journal Of Manual and Manipulative Therapy. June 2010;18(2):74-83.
Hooper T, Denton J, McGalliard M, Brismée J, Sizer P. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. Journal of Manual and Manipulative Therapy. June 2010;18(3):132-138.
Resources
NINDS Thoracic Outlet Syndrome Information Page
Clinical Bottom Line
TOS can present in numerous ways due to the variety of tissues that can be involved (arteries, veins, nerves, and muscular tissue) and the different anatomical sites in which compression or entrapment can occur. In general, treatment for TOS should initially begin conservatively according to a literature review by Vanti et al, however, firm conclusions cannot be drawn from this review due to the lack of high-quality evidence. Conservative treatment seems to be effective at reducing symptoms, improving function, and facilitating return to work when compared to surgery. Higher-quality studies are needed to compare the conservative treatment to surgery, and even no treatment at all. Physical therapy can assist patients given a TOS diagnosis utilizing an impairment-based approach, addressing muscle imbalances and postural changes that these patients commonly present with.
Presentations
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Conservative Management of Thoracic Outlet Syndrome Part 1
This presentation was created by Walt Lingerfelt, Fellow in training at Evidence in Motion.
Conservative Management of Thoracic Outlet Syndrome Part 1 / View the presentation
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Conservative Management of Thoracic Outlet Syndrome Part 2
This presentation was created by Walt Lingerfelt, Fellow in training at Evidence in Motion.
Conservative Management of Thoracic Outlet Syndrome Part 2 / View the presentation
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Related articles
Clinical Reasoning and Pathologies of the Thoracic Spine - Physiopedia
Introduction The thoracic spine is a complex area that has been largely overlooked in research.[1] While only 13 percent of individuals specifically report thoracic pain each year,[2] it is now recognised that the thorax can be a silent contributor to other distal and proximal conditions.[1] Moreover, a number of non-mechanical pathologies can masquerade as musculoskeletal thoracic pain. All of these conditions must be considered when assessing patients who have thoracic pain. Muscles of the Thorax[edit | edit source] There are 112 muscle attachments in the thorax. This page looks at some of the muscles that can affect the thorax. Additional information on thoracic spine musculature is available here. Intercostals[edit | edit source] There are 11 pairs of intercostal muscles. Each muscle has three layers arranged from superficial to deep:[3] External Internal Innermost The intercostal nerves mostly come from the anterior rami of the T1 to T11 spinal nerves.[3] Along with the intercostal artery and vein, these nerves run between the intermediate and deep layers of the intercostal muscles. The T7 to T11 intercostal nerves leave the thoracic wall and enter the abdominal wall to innervate the abdominal peritoneum.[4] They supply the:[4] Ribs and costal cartilages Intercostal muscles (all layers) Parietal pleura, which lines the inner surface of the thoracic cavity, including the diaphragm, pericardium and thoracic aorta Because of this shared innervation, diseases of the thoracic wall or cavity may masquerade as dermatomal pain arising from the thoracic spine.[4] Thus, it is essential to constantly assess a patient for red flags. If a patient has a poor response to treatment, this can indicate a more serious pathology and is considered a key red flag.[4][5] Iliocostalis[edit | edit source] Iliocostalis is the most lateral of the erector spinae muscles. It is divided into three parts:[6] Iliocostalis cervicis Iliocostalis thoracis Iliocostalis lumborum Iliocostalis lumborum originates at the iliac crest and inserts into the L1 to L4 lumbar transverse processes, the angle of ribs 4 to 12, and the thoracolumbar fascia. Iliocostalis cervicis and thoracis have attachments as high as the upper 6 ribs and the transverse processes of C4.[6] Iliocostalis, therefore, links lumbo-pelvic dysfunction with thoracic dysfunction. Hypertonicity in this muscle can potentially have an impact on the thoracic rings.[4] Pectoralis Major[edit | edit source] Pectoralis major makes up the bulk of the chest muscles. It is a thick, fan-shaped muscle that originates at the:[7] Anterior sternum (down to the xiphoid process) Clavicle 6th rib (sternal end) Upper 6 costal cartilages Aponeurosis of the external oblique It inserts into the lateral lip of the bicipital groove on the humerus.[7]It also has fascial links with latissimus dorsi.[4][8] Overactivity of pectoralis major is associated with thoracic kyphosis and anterior translation of the humerus.[4] Horizontal clavicles are a clinical sign of overactivity in this muscle.[4] Pectoralis stretching can help to reduce kyphosis, as well as forward head position / rounded shoulder position and upper-crossed syndrome.[9][10] Figure 1. Exercise to reduce thoracic kyphosis. The exercise shown in Figure 1 can be used to improve thoracic and scapula motor control. It can also reduce thoracic kyphosis by increasing the activity of the middle and lower fibres of trapezius and reducing overactivity in the upper fibres of trapezius.[4] NB: it is important to improve activation of lower trapezius in patients who have an increased thoracic kyphosis. The cue “down and out” should be given during exercises, rather than “down and in”.[4] See also Scapular Dyskinesia Rhomboid Major and Minor[edit | edit source] The rhomboids consist of two muscles:[11] Rhomboid major A quadrangular muscle Inferior to rhomboid minor Originates at the T1 to T4 spinous processes Inserts into the medial margin of the scapula below the root of the inferior angle[4] Rhomboid minor A cylindrical muscle Originates at the ligamentum nuchae and C7 and T1 vertebra Inserts into the medial margin at the root of the spine of the scapula Overactivity in these muscles leads to:[4] Inverted thoracic spine (also known as a lordotic thoracic spine) with compression forces on the facets Downward rotation of the scapula, which loads the cervical spine Dural irritation Serratus Anterior[edit | edit source] Figure 2. Hug an aunt stretches for serratus anterior. Serratus anterior is a fan-shaped muscle. It lies deep to the scapula and pectoral muscles:[12] It originates on the superolateral surfaces of the upper 8 or 9 ribs It runs backwards and inserts along the superior angle, medial border, and inferior angle of the scapula This muscle is a powerful protractor (abductor). It is also involved in upward rotation (which allows for overhead activity), posterior tilt and external rotation of the scapula. It holds the scapula flat against the rib cage and can mobilise the thoracic spine into kyphosis.[4][12] The exercises shown in Figure 2 are useful for:[4] Inverted thoracic spine (see above) Possible dural pain Targeting the various digitations of serratus anterior External Oblique vs Serratus Anterior[edit | edit source] External oblique, internal oblique and transversus abdominis are the three anterolateral abdominal wall muscles. The external oblique is the largest, thickest and most superficial of these muscles:[4][13] It attaches to the lower 6 or 7 ribs (and, therefore, can affect the activity of the diaphragm)[4] It runs obliquely from superior-lateral to inferior-medial It inserts on the iliac crest The external oblique and serratus anterior interdigitate from the 5th to the 9th ribs.[4] The opposing action of these muscles (e.g. during rowing or coughing) creates a stress reaction, which is a major contributor to stress fractures.[14] The Diaphragm[edit | edit source] The diaphragm is a dome-shaped muscle of respiration that is innervated by the phrenic nerve (C3-5). The superior portion of the diaphragm originates at the:[15] Xiphoid process anteriorly The lower 6 costal cartilages of the thorax laterally via digitations that cross those of transversus abdominis[16] The first two lumbar vertebrae posteriorly It converges into a central tendon which forms the dome’s crest. The peripheral segment attaches to the chest wall and abdominal cavity.[15] The diaphragm is connected via fascia to the:[4] Aortic system Inferior vena cava Liver Psoas muscles Quadratus lumborum Transversus abdominis Pelvic floor Cardiac system (pleura and pericardium) Deep and median neck fascia Occiput Dura Phrenic-oesophageal ligaments Kidneys The diaphragm and intercostals are the only muscles that are active during quiet inspiration.[17] During quiet exhalation, the diaphragm, rib cage and chest wall relax and return to their original position, which expels the air from the lungs.[15] The diaphragm is, therefore, essential for optimal respiratory physiology. It also affects many other systems as well, including the nervous system, muscle and postural systems, as well as the lymphatic system.[4][17] The Effect of Diaphragmatic Bracing on the Thoracic Spine[edit | edit source] Diaphragmatic bracing in low load situations can occur in:[4] Chronic low back pain[18] PTSD Panic attacks COVID-19 Figure 3. 90/90 bridge with ball and balloon exercise. Patients who engage this bracing strategy may present with back, thoracic, neck and rib pain. Bracing fixes the thoracic wall and reduces thoracic mobility. It can lead to:[4] Hypocapnia (i.e. decrease in carbon dioxide levels) Increased respiratory rate Apical breathing Irregular respiratory rate Normally, ribs 1 to 7 posteriorly rotate during full inspiration and anteriorly rotate during full expiration.[19][20] It is important to teach patients correct respiration as optimal breathing mechanics promote synchronous movement of the ribs. The 90/90 bridge with ball and balloon exercise (see Figure 3) was created to enhance function and breathing, improve posture and stability and to reduce pain.[21] Pathologies[edit | edit source] Spinal Masqueraders[edit | edit source] In some instances, thoracic pain may have non-mechanical origins. Visceral or systemic conditions that present as thoracic pain are known as spinal masqueraders. Examples of thoracic spinal masqueraders include:[4] Pneumothorax Pleuritic pain Coronary heart disease Oesophageal pain Tumours (e.g. lung) Liver and spleen conditions Herpes zoster Seronegative arthritis Ankylosing spondylitis Pneumonia Malignant lymphoma Stomach ulcers Thoracic Outlet Syndrome[edit | edit source] Thoracic outlet syndrome (TOS) is a group of disorders that cause compression of the nerves, arteries or veins as they exit the thoracic outlet. TOS typically occurs in three places:[4] Scalene triangle Costoclavicular space Retropectoral space Postural / thoracic kyphosis, tight bra straps, overactive subclavius, and the presence of a cervical rib can narrow the costoclavicular space and create neurovascular symptoms.[4] Structures usually affected in TOS are the:[22] Subclavian artery and vein Axillary artery and vein Brachial plexus There are three types of TOS:[22][23] Neurogenic (i.e. brachial plexus) Most common type (approximately 95 percent of cases[24]) Symptoms include: Pain Weakness Heaviness in the arm Paraesthesia Neurogenic symptoms tend to be worse with overhead activities or when the patient's arm is dangling at his / her side Venous (i.e. subclavian vein) - also known as Paget–von Schroetter syndrome[24] Symptoms include: Swelling Pain Bluish discolouration Arterial (i.e. subclavian artery) Least common type Symptoms include: Pain Coldness Paleness in the arm TOS is often missed by clinicians - the average time to diagnosis is 60 months. TOS may be mistaken for carpal tunnel, cervical nerve root compression, psychosocial issues, complex regional pain syndrome, fibromyalgia, MS etc.[4] TOS can be diagnosed using the following tests and investigations:[25] Adson’s test Elevated arm stress test (Roos test) It has been found that using the Adson and Roos tests as a cluster results in higher specificity than using these tests on their own[24] Upper limb tension test Nerve conduction study (0ften negative) MRI in elevation Doppler / duplex ultrasound Scalene blocks can be used as a diagnostic tool[23] Warm and cold thermal detection also has good reliability[26] Stress Fracture of the Ribs[edit | edit source] Stress fractures of the ribs are typically associated with sports that have:[4] High strain magnitudes (e.g. weightlifting) High load repetitions (e.g. golf, rowing, throwing, over-training) They tend to occur when the opposing actions of serratus anterior and external oblique generate pulling forces and, consequently, a stress reaction (see above).[14] Rowing: The incidence of rib stress fractures in rowing is between 6 and 12 percent:[27] Occurs most often in ribs 5 to 9 Typically antero-lateral, but can be postero-lateral[14] Golf:[28] Most commonly occurs on the lead-side (i.e. non-dominant side) and affects the postero-lateral ribs Ribs 4 to 6 are most often affected Rib stress fractures are diagnosed based on history and bone scans, CT or MRI.[4] Patients usually require 3 to 9 weeks off sports.[4][29][30] Patients tend to present with:[29] History of insidious onset (overload) with sudden pain Pain with deep breathing, coughing, sneezing, turning in bed Inability to sleep on the affected side Severe, specific, palpable pain on examination Positive rib spring Altered breathing mechanics Pain with push-up and with resisted serratus anterior testing Pain with sit-up, including with an oblique bias Manubriosternal Joint Pain[edit | edit source] Manubriosternal joint pain often occurs as a result of an acceleration / deceleration injury[31] (e.g. throwing, serving). Sclerosis of this joint is also seen in various types of arthritis, including:[4] Axial spondyloarthritis / ankylosing spondylitis Reactive arthritis / Reiters Psoriatic arthritis Rheumatoid arthritis Costochondritis[edit | edit source] Costochondritis is inflammation of the costochondral or chondrosternal joints. It is more common in adults aged over 40 years. In 90 percent of patients, more than one rib is affected. The ribs most frequently affected are ribs 2 to 5.[32] Mild to severe localised pain, but may refer to the shoulder, neck and arms[4] It is important to rule out seronegative arthritis, pneumonia, cardiovascular and malignant disorders[4] It is treated with NSAIDs and it can take weeks or months to resolve[32] Costochondritis can be mistaken for Tietze syndrome, but this condition is characterised by swelling of a single costal cartilage. Ribs 2 or 3 are usually affected and it is more common in younger patients.[32] Cervical Facet Pain[edit | edit source] It is well established that cervical discs, as well as cervical facet joints refer pain to the upper thorax.[4] Thoracic Disc Pathology[edit | edit source] Thoracic disc pathology is rare and individuals are often asymptomatic. One of the reasons it is so rare is due to the thickness of the thoracic disc - it is thinner than in other regions. The ratio of the thoracic disc to the vertebral body is 1:5 (vs 2:5 in the cervical spine and 1:3 in the lumbar spine).[4] Figure 4. Spinal dermatomes. In 75 percent of cases, thoracic disc pathology occurs at T8 or below, peaking around T11 or T12.[33] Only 1 percent of prolapses with severe myelopathy occur in the thoracic spine.[4] There are two types of disc pathology:[4] Central thoracic pain (myelopathic): Leg paralysis and spinal cord compression Bladder and bowel impairment Dermatomal unilateral pain (radicular) Compression of the nerve root[4] Pain follows the intercostal dermatomal route (see Figure 4) Summary[edit | edit source] It is beneficial to restore a neutral thoracic spine Serratus anterior is key to restoring an optimal thoracic kyphosis from a dysfunctional inverted position Teaching correct respiration is important as good breathing mechanics prompt synchronous movement of the ribs As there are many thoracic spinal masqueraders, red flags should be constantly assessed: A key red flag to consider is a poor response to treatment
First Rib - Physiopedia
Description The first rib is the most superior of the twelve ribs. It is an atypical rib and is an important anatomical landmark. It is one of the borders of the superior thoracic aperture.[1] The ribs form the main structure of the thoracic cage that protects the thoracic organs. There are 12 pairs of ribs which are separated by intercostal spaces. The first seven ribs progressively increase in length, the lower five ribs then begin to decrease in length. Ribs are highly vascular and trabecular with a thin outer layer of compact bone. Similar to the first rib, the 11th and 12th ribs are considered atypical ribs due to their anatomical features[2]. The remaining ribs are typical. Anatomy[edit | edit source] When compared to a typical rib, the first rib is Short and thick and only has a single articular facet for the costovertebral joint. The first rib Has a head, neck and shaft but lacks a discrete angle[3]. The shaft is indented laterally, the groove for the subclavian artery, which contains the lowest brachial plexus trunk as well as the subclavian artery. Anterior to the scalene tubercle is another groove for the subclavian vein. There is no costal groove on its inferior surface. It has two tubercles: transverse tubercle: posterior and lateral to the neck; bears an articular facet for the transverse process of T1 scalene tubercle: anteriorly between the grooves for the subclavian artery and vein; anterior scalene muscle inserts here, it is also known as the Lisfranc tubercle, described by Lisfranc in 1815 Blood Supply[edit | edit source] Arterial blood supply arises from the internal thoracic and superior intercostal arteries. The internal thoracic artery supplies the anterior body wall and its associated structures from the clavicles to the umbilicus. It originates from the first part of the subclavian artery in the base of the neck. The superior intercostal arteries are formed as a direct result of the embryological development of the intersegmental arteries. These arteries are paired structures of the upper thorax which normally form to provide blood flow to the first and second intercostal arteries.[4] Venous drainage is to the intercostal veins. Innervation[edit | edit source] The first rib is innervated by the first intercostal nerve. The intercostal nerves are part of the somatic nervous system, and arise from the anterior rami of the T1 to T11 thoracic spinal nerves The intercostal nerves are distributed chiefly to the thoracic pleura and abdominal peritoneum and differ from the anterior rami of the other spinal nerves in that each pursues an independent course without plexus formation.[1] The first intercostal nerve is joined to the brachial plexus through a branch, which is equivalent to the lateral cutaneous branches of remaining intercostal nerves. Another exception with the first intercostal nerve is that there is no anterior cutaneous branch. It is also very small as compared to the remaining nerves[5]. Attachments[edit | edit source] The first rib has several attachments which are listed below; Anterior scalene muscle: scalene tubercle Middle scalene muscle: between groove for the subclavian artery and transverse tubercle Intercostal muscles: from the outer border Subclavius muscle: arises from the distal shaft and first costal cartilage First digitation of the serratus anterior muscle Parietal pleura: from the inner border Costoclavicular ligament: anterior to the groove for the subclavian vein Palpation[edit | edit source] The first rib is often noted as the most difficult rib to palpate. To palpate the first rib, find the superior border of the upper trapezius muscle and then drop off it anteriorly and direct your palpatory pressure inferiorly against the first rib. Asking a patient to take in a deep breath will elevate the first rib up against your palpating fingers and make palpation easier Examination[edit | edit source] First Rib Assessment on hypomobility in Supine: [6] Assessing Rib Mobility - Lindgren's Test: [7] Pathology/Injury[edit | edit source] The first rib, in particular is involved in thoracic outlet syndrome and Pancoast tumour. Thoracic Outlet Syndrome The term ‘thoracic outlet syndrome’ describes compression of the neurovascular structures as they exit through the thoracic outlet (cervicothoracobrachial region)[8]. The thoracic outlet is marked by the anterior scalene muscle anteriorly, the middle scalene posteriorly, and the first rib inferiorly. The term ‘TOS’ does not specify the structure being compressed. 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[9]. 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. 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[9]. Pancoast tumour Or otherwise known as superior sulcus tumour, refers to a relatively uncommon situation where a primary bronchogenic carcinoma arises in the lung apex at the superior pulmonary sulcus and invades the surrounding soft tissues. Although classically superior sulcus tumours present with Pancoast syndrome, this is only the case in approximately 25% of cases[10]. The missing element is usually Horner syndrome. The most common symptoms at presentation are chest and/or shoulder pain, with arm pain being also common. Weight loss is frequently present[11]. The first rib os also affect by pathology common to all ribs; infection, e.g. septic arthritis, osteomyelitis malignancy, e.g. chondrosarcoma, enchondroma, metastases trauma, e.g. fracture first rib fractures are often associated with clavicle fractures or damage to adjacent neurovascular structures
Middle Scalene - Physiopedia
Description Middle scalene or scalenus medius (Latin: musculus scalenus medius), is the largest and longest muscle in the scalene group of lateral neck muscles.[1] Often penetrated by the dorsal scapular[1] and long thoracic nerves[2], it is deeply placed, lying behind sternocleidomastoid[2]. Origin[edit | edit source] It originates from the transverse process' posterior tubercles of C2 to C7.[2][3]. Origin deviations can include the transverse transverse process of the atlas [2][1][4]. Insertion[edit | edit source] The tendon inserts onto the superior border of the 1st rib, anterior to the 1st rib's tubercle and posterior to the subclavian groove.[1][2][3].Insertion variations include insertion onto the 2nd rib[4][2]. Nerve Supply[edit | edit source] Anterior rami of cervical spinal nerves C3 - C8 [1][2][3]. Blood Supply[edit | edit source] The ascending cervical artery branch of the inferior thyroid artery supplies the middle scalene[2][3][1]. Action and Function[edit | edit source] The middle scalene work with the anterior scalene to elevate the first rib during respiration[1][3] and are also strong ipsilateral flexors during unilateral contraction[3][1]. The middle scalene are also involved with cervical rotation[3][2]. Clinical significance[edit | edit source] The interscalene triangle (scalene triangle) is the anatomical triangle formed between the scalenus anterior muscle (anteriorly), the scalenus medius muscle (posteriorly) and the first rib (inferiorly)[1][4]. Structures including the subclavian artery and brachial plexus pass through it[1]. Abnormal anatomy or injury to this region can cause compression of the neurovascular structures leading to thoracic outlet syndrome (TOS)[2][4]. TOS typically leads to paraestheisa, pain and weakness in the ipsilateral upper limb[2]. Please see the page on TOS for more information regarding this syndrome.
Costoclavicular Syndrome - Physiopedia
Introduction The costoclavicular passage is one of three passages that consitute the thoracic outlet; the others are the superior thoracic outlet and the costoscalene hiatus.[1] The costo-clavicular passage is formed by the clavicle antero-laterally, the first rib medially, and the scapula posteriorly.[2] The brachial nerve plexus, subclavian artery and subclavian vein run within the costoclavicular space between the first rib and the clavicle. The neurovascular bundle is vulnerable to compression in this space.[2] Mechanism[edit | edit source] The costoclavicular syndrome was first described in soldiers with loaded knapsacks, who developed pain, numbness, and fatigueability of the arms as they stood at attention.The mechanisms of compression involved downward movement of the clavicle against the first rib with a resultant tendency to shearing of the neurovascular bundle.[3] This can occur in three ways: The clavicle depresses toward/against the first rib. This can be observed in the common postural condition of rounding and slumping shoulders. This narrows the costoclavicular passage by pushing the scapula forwards. A tight subclavius can also cause this to occur.[4] A similar mechanism operates in usually obese, middle aged or elderly women. Tight, narrow brassiere straps supporting heavy breasts cut into the soft tissues around the shoulders and exert direct downward pressure on the clavicles, usually around the junction of the mid and lateral thirds. A scissoring action of the clavicle against the first rib narrows the costoclavicular passage and shears the neurovascular bundle.[2] The first rib elevates toward/against the clavicle. This often occurs in clients who have laboured breathing. Tight anterior and middle scalenes and subclavius can also cause this to occur.[4] The clavicle depresses and the first rib elevates.[4] Presenting Complaints[edit | edit source] Pain or ache sometimes accompanied by stiffness in the neck and shoulders, pain, paraesthesiae, and fatigueability of the upper limbs are the main presenting complaints. Symptoms are usually bi-lateral, though more pronounced on the dominant side. They are aggravated by work and exercise, particularly carrying heavy shopping bags. Symptoms are relieved by rest and sleep, are minimal or absent in the morning, and become pronounced as the day progresses. Patients occasionally complain of puffy blue hands.[2] Examination[edit | edit source] The most important clues to diagnosis are the deep grooves on both shoulders where tight, narrow bra straps have cut deeply into the underlying soft tissues. Direct downward pressure with a forefinger in the groove reproduces symptoms. Invariably, there is tenderness over the acromioclavicular joint. Movements of the neck and shoulder are free. The former are painless, but shoulder movements may be slightly painful because of osteoarthritis of the acromioclavicular joint. There is no muscle wasting or weakness. Paraesthesiae when present are likely to involve the thumb and all fingers and sometimes the whole limb. They differ from the paraesthesiae of carpal tunnel compression in their distribution and timing. Phalen’s Test and Tinel’s Test are absent. Some patients complain of puffy blue hands. They lack the classic colour changes of Raynaud's phenomenon and are unaffected by cold. The normal appearance of the hand in the costoclavicular syndrome helps to differentiate it from the shoulder-hand syndrome, where it is shiny, swollen, warm, and hyperaesthetic. Patients with this form of costoclavicular syndrome are usually younger than those with polymyalgia rheumatica, customarily a disease of the over sixties. In polymyalgia rheumatica shoulder stiffness is prominent and bilateral and may be accompanied by symptoms of systemic upset or arteritis, e.g. visual disturbances, headache, etc. Great care must be taken to exclude the other causes of neck, shoulder, and arm pain. [2] Costoclavicular / Military Brace / Eden's Test is positive Investigations[edit | edit source] No abnormalities are detected on routine blood tests, full blood count, erythrocyte sedimentation rate, and immunological tests for inflammatory arthritis. The long duration of symptoms, normal blood tests, and x rays usually showing no more than minimal degenerative change of the cervical spine and acromioclavicular joint exclude most other conditions to be considered in the differential diagnosis. The approximation of the clavicle to the first rib that occurs when direct downward pressure is applied on the grooves of the shoulder or on loading is difficult to demonstrate radiologically. This is due to technical difficulties in obtaining radiographs of comparable quality and of placing markers on the first rib. The subluxation of the acromioclavicular joint may sometimes be seen.[2] Medical Management[edit | edit source] Firstly, the goal is to open the space between the clavicle and first rib. After placing moist heat on the region for approximately five to ten minutes, begin by working within the costoclavicular space itself. The subclavius muscle is located here and, when tight, can decrease the space by pulling the clavicle and first ribtoward each other. In addition to the subclavius, the entire costoclavicular space should be worked in case fascial adhesions are present.The tissues of the costoclavicular space should now be stretched by passively bringing the client’s arm back into extension and up into abduction. This stretch is easiest to perform with the client seated or standing. It can be done with the supine client if the client is lying at the side of the table. Secondly, any other muscles that can either elevate the first rib into the clavicle or depress the clavicle into the first rib should be worked. These include the scalenes, pectoralis minor and pectoralis major The next step is the elimination of the cause of symptoms. Patients must be advised to wear either strapless brassieres or brassieres with broad straps with a pad threaded through the strap and placed in position on the shoulders. These measures help to distribute the downward force exerted by the straps. The straps must not be too tight. Patients must avoid carrying heavy shopping bags. The use of a shopping trolley solves this problem. Attention to posture directed at avoiding stooping and shoulder girdle exercises helps. Weight reduction though seldom resulting in significant reduction in the weight of the breasts helps, if only to increase the sense of general wellbeing. Pain and tenderness in the acromioclavicular joint usually respond to a reduction of the distracting forces on the joint produced by the measures outlined. Some may need treatment with local ice or heat and simple analgesics. Occasionally an injection of corticosteroid and local anaesthetic into the acromioclavicular joint may be required. In extreme cases surgical reduction of breast size by mammo-plasty produces excellent results.[2][4]
The Axillary Region - Physiopedia
Description The axillary region (also known as the arm pit) is a pyramid-shaped area located between the shoulder girdle and thorax. It serves as a space for neurovascular and lymphatic structures to travel through to reach the upper extremity from the neck[1]. Structure/Borders[edit | edit source] Apex: (also known as cervicoaxillary margin, axillary inlet) region of entrance/exit of the axillary neurovascular bundle 1st rib Scapula (superior portion and coracoid process) Clavicle [1][2] Base: Axillary skin Fascia Axillaris Anterior Wall: Pectoralis major Pectoralis minor Posterior Wall: Subscapularis Latissimus dorsi Teres major Medial Wall: Ribs 1-4 Intercostal muscles of ribs 1-4 Serratus anterior Lateral Wall: Intertubercular groove of the humerus[3] The structure of the axilla is dependent upon the position of the upper extremity - an expansive region when the arm is elevated and minimized when adducted[2]. [4] Contents[edit | edit source] The axillary artery is an extension of the subclavian artery, and is called so after passing the first rib. It is renamed and considered the brachial artery after passing the teres major and exiting the axilla. The artery is encompassed by the axillary sheath and the brachial plexus cords and branches. The axillary artery is divided into three parts with arterial branches associated with each section. The branches of the axillary artery include the superior thoracic, thoracoacromial, lateral thoracic, subscapular, anterior humeral circumflex and posterior humeral circumflex arteries. The scapular and humeral anastomoses created by these branches are important factors to compensate if there are any occlusions of the axillary artery[3]. The brachial plexus' cords and branches surround the axillary artery and are named in reference to their position relative to the artery. The nerves of the brachial plexus course past the first rib, inferior to the clavicle and through the axilla from its cervical and thoracic roots (C5-T1) towards its peripheral innervation destinations. Within the axillary region, the brachial plexus gives rise to peripheral nerves, including the medial and lateral pectoral, medial cutaneous of arm and forearm, upper and lower subscapular, and thoracodorsal nerves, supplying muscles of the shoulder girdle and chest as well as sensation to certain areas of the upper extremity[2]. Medial to the axillary artery lies the axillary vein, receiving deoxygenated blood from the cephalic vein, basilic vein, and other tributaries correlating with branches of the axillary artery, ultimately serving as the major vessel of drainage for the upper extremity[1][2]. The axillary vein becomes the subclavian vein after exiting the apex of the axilla. Like the axillary artery, the axillary vein features anastomoses to compensate for any blockages that may form[2]. Axillary lymph vessels and nodes process lymph from the upper extremity and chest. The superficial vessels drain the skin while the deep vessels drain the bones and muscles. There are five groups of axillary nodes present in the axilla including pectoral, lateral, posterior (subscapular), central, and apical[3]. In addition to the neurovascular bundle, the axillary region also contains the short head of the Biceps Brachii muscle, coracobrachialis muscle, fascia and adipose tissue. Mammary tissue is also possibly present[2]. Clinical Relevance[edit | edit source] Thoracic Outlet Syndrome (TOS) results from the compression of nerves and/or vessels at or around the apex of the axilla. The clinical presentation and distribution of TOS is dependent upon the structures compressed. A patient with TOS may complain of ipsilateral upper extremity pain, parasthesia, paresis, discoloration, and/or cold sensitivity[3]. See the content page on TOS for more information. The breast is mostly drained through the axillary lymph vessels and nodes. Breast cancer can spread to the surrounding lymphatic system as well as the pectoralis major muscle and it's fascia. Decreased filtration of the axillary lymph nodes from cancerous infiltration, damage, or surgical removal as a form of treatment can result in swollen axillary lymph nodes or upper extremity lymphedema[3]. An additional risk of surgical removal is the damage of the long thoracic nerve, which would clinically present as scapular winging due to the resulting denervation of the serratus anterior muscle[1]. If the neck or upper extremity is forcefully stretched or trauma is inflicted upon the axillary region a brachial plexus injury may result. The clinical presentation of a brachial plexus injury is dependent upon the specific nerves and nerve roots damaged. It results in loss or diminishment of sensation and motor control of the associated innervation of the nerve(s) damaged. Upper trunk injuries (C4-C6) are more common than lower trunk injuries (C7-T1). Brachial plexus injuries may also be a result of a cervical rib or apical lung cancer growth[3]. See the content page on brachial plexus injuries, Erb's palsy, and Klumpke's palsy for more information. If not properly fit, positioned and trained, axillary crutches can cause unnecessary pressures and damage to the contents of the axilla[3]. A clinician should also consider which type of crutch (axillary, forearm, gutter) or assistive device is most appropriate for the patient. See the content page on crutches for more information of proper fitting. Related Pages[edit | edit source] Shoulder Brachial Plexus Thoracic Outlet Syndrome Breast Cancer Lymphoedema Brachial Plexus Injury (Erb's Palsy and Klumpke's Paralysis) Crutches
References
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