Thoracic Outlet Syndrome
The thoracic outlet is the
area of the shoulder/neck where the nerves (brachial plexus) and blood
vessels (subclavian vessels) pass from the cervical area toward the axilla.
Thoracic outlet syndrome (TOS) is a set of symptoms due to compression
and/or irritation of these vessels and nerves. There is much controversy
among physicians and diagnosing this syndrome is very difficult.
It is often confused with carpal tunnel syndrome, brachial plexus syndrome,
rotator cuff syndrome and bursitis.
Disc protrusion, herniation
or degeneration causing nerve impingement
Brachial plexus entrapment or
subclavian artery compression in the interscalene triangle (usually between
anterior and medial scalene)
Impingement at the cervico-axillary
canal or the costo-clavicular space (1st rib) -could be from carrying a
heavy shoulder bag or bad posture
Fibrositis of the cervical and
shoulder area (pectoralis major and minor, the posterior cervical triangle)
Cervical spondylosis -irritation
or compression of the C3-C8 spinal nerves causing increased tension and
spasm in anterior scalene muscles.
Extra first rib (cervical rib)
Bone spurs on cervical vertebrae
(may be called extra first rib)
Trauma such as whiplash (hyperextension)
or other injury to the neck that results in scar tissue formation in scalenes
which lead to compression
Trauma to the shoulder
Old fractures of the clavicle
that limit space for vessels.
Postural distortions caused
by pec minor and minor, SCM, scalenes, trapezius, levator scapulae; forward
head, rounded shoulders, scoliosis (psoas imbalance), kyphosis
Loss of curvature in the neck
due to Longus coli shortening
Excessive exercise leading to
shortening of the shoulder and neck muscles
Shallow breathing -hypertrophy
of scalene muscles
Postural changes due to pregnancy
Anterior scalene tightness
Pectoralis minor tightness
Paresthesia of the hand most
commonly little finger, medial forearm and arm; Pins and needle feeling
Weakness in trapezius
Swelling or puffiness in arm
Bluish color in hand, coldness
in hand and fingers due to loss of circulation: insufficient blood supply
due to compression of subclavian artery
Muscles in hand atrophy in chronic
Edema/swelling in hand caused by compression
of subclavian vein
Pain in neck
Weakness in hands and arms especially
when raising overhead
Dull shooting pain down the
Feeling of heaviness in arms
difficulties with fine motor skills of hands
The following test may help
to locate the areas of impingement. These test may not be reliable
and conclusive. Palpation of the area may prove to be more helpful in finding
the source of impingement.
East Test or hands up test
-client brings hands up above head, with elbows slightly back and opens
and closes hands slowly for 3 minutes. Pain, heaviness or weakness
and numbness are positive signs
Adson or Scalene Maneuver-
Find the radial pulse. Have the client look to the side and up
toward the ceiling while holding the pulse. Check for diminishing pulse.
Hold the same wrist and have client rotate head to opposite side and up
toward the ceiling. A positive sign indicates neurovascular impingement
between the anterior and medial scalene or the presence of a cervical rib.
- Find the radial pulse. Have the client pinch their shoulder blades
together and tuck the chin in towards the chest. Check for diminishing
pulse. A positive sign is an absence of pulse and indicates compression
of the neurovascular bundle between the first rib and the clavicle. This
may be due to scalene and subclavius tightness.
Wright's Test - Find
the radial pulse. Passively raise arm out to the side and above the
head (abduction of shoulder ) holding for
several seconds. Check for diminishing pulse. A positive sign indicates
pectoralis minor or coracoid process compression.
Traction Test - Find
the radial pulse. Apply firm traction on the arm for several seconds
checking for diminishing pulse. A positive sign indicates cervical
rib pressure on the tested side.
see the tests online:
Neck muscles- view
and upper arm Nerves
System in Neck/Axilla
Treatment Goals: Release
adhesions causing nerve entrapment, reduce muscle spasming or contractures
causing nerve entrapment.
Work all muscles of the shoulder,
neck and upper back; Scalenes, trapezius, SCM, pectoralis major and minor,
subclavius, rhomboids. Use Trigger Point therapy.
Correct postural deviations.
Look at the whole body and see how the shoulders and neck are influenced
by the lower body.
Re-educate and increase awareness
a Massage Therapist
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