Thoracic Outlet Syndrome

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Thoracic Outlet Syndrome

• TOS

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Thoracic Outlet Syndrome

• Thoracic outlet syndrome results from compression
  of the subclavian vessels and brachial plexus.
• Patients may complain of neck and shoulder pain
  with numbness and tingling in the upper
  extremity.
• The ulnar side is typically involved.
• Using the extremity in an overhead or elevated
  position is difficult.

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Clinical Signs and Symptoms

• Upper extremity pain.
• Upper extremity paresthesias.
• Grip weakness.

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Clinical Signs and Symptoms

• Upper extremity edema.
• Upper extremity coldness.
• Excessive dryness of the arm or hand.
• Excessive sweating of the arm or hand.

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Thoracic Outlet
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Thoracic Outlet
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Adsons Test

• Procedure
• Patient seated establish amplitude of pulse.
• Compare amplitude b/l.
• Deep breath. Rotate head and elevate chin to
  side being tested.
• Repeat to opposite side.
• Positive Test
• A decrease or absence of the radial pulse.
• Paresthesias or radiculopathy in the upper
  extremity.

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Adsons Test

• Structures Affected
• Compression of the vascular component of the
  neurovascular bundle (subclavian artery) by one
  of the following
• Spastic or hypertrophied scalenus anterior muscle
• Cervical rib
• Mass such as a Pancoast tumor.
• Compression of the neural component of the
  neurovascular bundle (brachial plexus).

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Adsons Test
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Costoclavicular Test

• Procedure
• Patient seated establish radial pulse.
• Patient force shoulders posterior and flex chin
  to chest.
• Positive Test
• Decrease or absence of the radial pulse.
• Paresthesias or radiculopathy in the upper
  extremity.

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Costoclavicular Test

• Structures Affected
• Compression is caused by a decrease in the space
  between the clavicle and the first rib.
• A recent or healed fracture of the clavicle or
  first rib with or without callus formation,
  dislocation of the medial aspect of the clavicle,
  or spastic or hypertrophied subclavius muscle
  could cause the compression.

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Costoclavicular Test
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Wrights Test

• Procedure
• Patient seated establish radial pulse.
• Hyperabduct the arm and take the pulse again.
• Positive Test
• Decrease or absence of the radial pulse.
• Structures Affected
• Compression of the axillary artery by a spastic
  or hypertophied pectoralis muscle or a deformed
  or hypertrophied coracoid process.

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Wrights Test
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Traction Test

• Procedure
• Patient seated establish radial pulse.
• Maintain pulse, extend and traction arm.
• Positive Test
• A decreased or obliterated pulse alone is not
  diagnostic however, when if the test is repeated
  on the other side and reveals no change it is
  positive.
• Structures Affected
• A subluxated or malpositioned first rib or a
  cervical rib.

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Traction Test
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Halstead Maneuver

• Procedure
• Patient seated establish radial pulse and note
  amplitude.
• With opposite hand, pull on the patients arm and
  have him hyperextend the neck.
• Repeat on opposite side.
• Positive Test
• Decrease or absence of the radial pulse.
• Radiculopathy in the upper extremity.

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Halstead Maneuver

• Structures Affected
• Decrease or absence of the pulse indicates a
  cervical rib, subluxation, or malposition of the
  first rib.
• A radicular component indicates compression of
  the brachial plexus by the scalenus anterior
  muscle.

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Halstead Maneuver
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Bracial Plexus Irritation

• Irritation of the brachial plexus may be due to
  various factors such as the following
• Cervical rib
• Severe upper traction of the arm
• Fractured clavicle
• Pulmonary apical mass

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Clinical Signs and Symptoms

• Upper extremity radicular pain
• Upper extremity paresthesias
• Grip weakness

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Brachial Plexus Stretch Test

• Procedure
• Patient seated.
• Laterally flex the head opposite to the side
  affected.
• Extend the shoulder and elbow on the affected
  side.

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Brachial Plexus Stretch Test

• Positive Test
• Pain and/or paresthesia along the distribution of
  the brachial plexus.
• Pain on the side of lateral bending may indicate
  a nerve root problem.
• Local cervical pain on the side of bending could
  be a facet joint problem on that side.

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Brachial Plexus Stretch Test