THORACIC OUTLET SYNDROME. John Broussard, DO Sports Medicine Fellow Institute for Non-Surgical Orthopedics Larkin Community Hospital

Transcription

1 THORACIC OUTLET SYNDROME John Broussard, DO Sports Medicine Fellow Institute for Non-Surgical Orthopedics Larkin Community Hospital

2 Definition A group of syndromes in which biomechanical obstructions are believed to compress or obstruct structures in the thoracic outlet Subclavian artery & vein Axillary artery Cords of brachial plexus

3 TOS Symptoms Arterial Numbness of arms/hands Tingling of arms/hands Positional weakness Discoloration (pale/white hands) Venous Swelling of fingers and hands Heaviness of UEs Discoloration (blue) Nerves UE pain Paresthesias of ulnar distribution Weakness of hands Clumsiness of hands Coldness of hands Tiredness, heaviness and paresthesias on elevation of UEs Shoulder and Neck Pain Tightness Chest Wall Anginal chest pain (heavy or squeezing in midsternal area of chest) Inter/para-scapular pain (along medial shoulder blade) Head Headaches funny feelings in face and ear Vertebral Artery Dizziness Lightheadedness

4 Anatomy Thoracic outlet? Borders Anteriorly: manubrium Posteriorly: Body of T1 Laterally: 1 st and 2 nd ribs (and their costal cartilage) Articulations Acromioclavicular Sternoclavicular

5 Anatomy Sibson s Fascia = cervico-thoracic fascia Runs from root of neck lower boundary of axilla (TP C7-border of rib 1) Tightly confines the neurovascular supply to the arm Great lymph channels (ascending and descending terminal ducts) pass through Sibson s fascia.

6 Anatomy Neurovascular bundle Subclavian a. (b/w 1 st rib and scalenes) Subclavian v. (anterior to anterior scalene) Brachial plexus (C5-T1) (more post. and lateral to subclavian a.)

7 Innervation Sympathetic Brachial plexus (C7-T1): shoulder girdle and upper extremity T1-T4: head, neck & brain T1-T8: upper extremity T1-T6: heart & lungs Parasympathetic Vagus: heart, lungs, upper GI, kidneys

8 Etiology All TOSs occur due to a disruption or alteration of the normal anatomy of the thoracic outlet. Symptoms of TOS are DIRECTLY related to the structures disrupted: Shoulder or arm pain Weakness Paresthesias Claudication Raynaud s phenomenon Ischemic tissue loss Gangrene

9 Predisposing Factors to TOS Intrinsic: Anterior scalene tightness Nerve root irritation, spondylosis, facet joint inflammation muscle spasm Pectoralis minor tightness Repetitive overhead activity (shoulder elevation & hyperabduction) Costoclavicular approximation (b/w clavicle, 1 st rib, support structures) Postural deficiencies or carrying heavy objects Cervical ribs Slender body habitus Extrinsic Trauma (contusion, hematoma, clavicular fx, whiplash) Unusual sleeping positions Occupations w/ unusual arm postures Painters, mechanics, military recruits, backpackers, students Athletes Swimmers, baseball pitchers, volleyball players, tennis players

10 Compression of neurovascular bundle 3 locations: b/w anterior and middle scalenes b/w clavicle and 1 st rib b/w pectoralis minor and upper ribs

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12 DDx of TOS Cervical nerve root compression (radiculopathy) Pancoast Tumor (lung apex reaches 2/3 cm into neck) Simple SD of ribs, clavicles, cervicals, thoracic spine Neurofibromas Cervical spondylosis Cervical disc herniation Carpal tunnel syndrome **Any/all may coexist w/ TOS**

13 Provocative Tests for TOS Adson s Test (b/w scalenes) Costoclavicular (Military posture) test (b/w clavicle & 1 st rib) Hyperabduction test (under pectoralis minor) Roos Test (Elevated Arm Stress Test) ER shoulders, elbows behind head. Open/close hands slowly x3 min. Pos: pain, heaviness or profound arm weakness or tingling/numbness Spurling Test (not specific for TOS) Adson s Test Costoclavicular Test Roos Test

14 Treatment Overview Protocol Identify type and cause of compression Optimize normal function and treat all somatic dysfunction Suggestions Exercise stretching program Correct biomechanics assess daily life movements of patient Why now? Meds: muscle relaxants, NSAIDs, Botox Biofeedback OMT Massage Physical Therapy Yoga

15 Treatment: OMT Myofascial release of thoracic outlet Normalize vertebral SD (C2-C7 and upper thoracics) Upper ribs (1 st rib superior subluxation w/ shortening of scalene muscles) Appendages (SC, AC, GH) Lymphatic treatment increase lymph flow TPIs Spray and stretch Acupuncture

16 OMT Upper Thoracic HVLA Chin pivot thrust Dysfunction: T1 FR L S L Patient in prone position w/ chin on table Stand at head of patient, opposite to posterior TP. Place left hypothenar eminence on left TP of T1. With right hand, SB pt s head to the right to max tissue tension while maintaining chin on table. Rotate head away to obtain max tissue tension. During exhalation, apply HVLA thrust w/ left hand directed anteriorly, laterally, and inferiorly while stabilizing the head w/ right hand. Recheck.

17 OMT SD: 1 st Rib inhalation Still Technique Patient supine. Standing at side of patient on side of dysfuntion. Flex pt s elbow and place their palm on chest. Place pads of index finger on pt s 1 st rib. Using opposite hand, grasp the elbow and apply longitudinal compression through humerus. Using the elbow as a lever, pt s arm is circumducted clockwise by moving UE medially until elbow lines up w/ head of pt s 1 st rib. The arc of motion from this position is lateral and inferior, continuing circumduction motion, and compression, w/ patient s arm ending at the midaxillary line. Recheck.

18 OMT Anterior & Middle Scalenes O: TP C2-C7 I: 1 st Rib A: Flexion and sidebending of C-spine Counterstrain Find the tender point, wrap around it. Hint: Follow the action of the muscle. Hold until tissues relax, passively return to resting. Recheck. May add traction and passively return to rest (Still) if no improvement.

19 OMT Pectoralis minor muscle O: Anterior surface ribs 3-5 I: Via tendon to medial aspect of coracoid process of scapula. (Part or all of tendon may transverse this process and continue into coracoacromial ligament) A: Scapula protraction, rotation of scapula downwards Counterstrain Find the tender point, wrap around it. Hold until tissues relax, passively return to rest. Recheck.

20 OMT Cervicles Whichever you are comfortable with or patient (or tissues) will allow: Counterstrain Still s HVLA Caution against muscle energy

21 Treatment Self-Stretching Scalenes and pectoral muscles Hold 30 sec., 10 reps bid WILL exacerbate symptoms Pain (deep ache) should not persist after stretch released Strengthening exercises for trapezius and levator scapulae Massage Cross-friction (pec minor and scalenes) Shoulder girdle

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23 References DiGiovanna E, Schiowitz S. An osteopathic approach to diagnosis and treatment. Philadelphia; JB Lippincott Co, 1991: Kai Y, Oyama M, Kurose S, et al. Neurogenic thoracic outlet syndrome in whiplash injury. J Spinal Disord 2001;4: Karageanes S. Principles of Manual Sports Medicine. LWW, 2005: Kulund DN. The injured athlete, 2 nd ed. Philadelphia: JB Lippincott Co 1988.