Thoracic outlet syndrome

Abstract: Thoracic outlet syndromes (TOS) describe a group of disorders that refer to compression of the brachial plexus or the subclavian vessels as they pass through the thoracic outlet. Ninety percent of TOS patient complaints are neurological in nature.These syndromes can be named according to the location of compression or the cause of symptoms. Many factors predispose patients to the development of TOS, such as occupation, gender, medical conditions, and genetic anomalies. Diagnosis is largely based on the history and physical examination findings. Most patients respond well to conservative care, but success in conservative management depends on an accurate assessment and development of a treatment plan specific to the patient's needs.

Keywords: Thoracic outlet syndrome, soft tissue therapy, Trigenics

Introduction: Thoracic outlet syndrome (TOS) was first identified by SirAshley Cooper in 1921 and was coined by Rob and Standeven in 1958.' By definition,TOS refers to compression of the brachial plexus and the subclavian vessels at the upper opening of the thorax.2 This region is constrained by the anterior middle scalene muscles, clavicle, and first and second ribs. Within this area, the brachial plexus exits the cervical spine and passes between the anterior and middle scalene musculature, and under the clavicle and pectoralis minor muscle, along with the subclavian artery and vein. It should however, be noted that the subclavian vein does not pass between the two scalene muscles before passing through the posterior aspect of the clavicle.

TOS is characterized by pain, numbness, tingling, and/or weakness in the arm and hand due to compression against the brachial nerves and subclavian vessels as they traverse the course from the cervical nerve roots to the axilla through the thoracic outlet and cervicoaxillary canal.

This article will provide a detailed clinical overview, categorization, and treatment options for TOS. A novel treatment for TOS utilizing Trigenics, a neuromuscular soft-tissue procedure, will be discussed in Part II.

Etiology and Categorization

TOS can be named in different ways. Medically, TOS is categorized largerly on the following syptom:3

True neurologicTOS is the only clearly defined type that most scientists agree on.The disorder is rare, typically painless, and caused by congenital anomalies (unusual anatomic features present at birth). It generally occurs in middle-aged women and almost always on one side of the body. Symptoms include weakness and wasting of hand muscles, and numbness in the hand.3

Disputed 70S, also called common or non-specific TOS, is a highly controversial disorder. Some doctors do not believe it exists, while others say it is very common. Because of this controversy, the disorder is referred to as "disputed TOS." Many scientists believe disputed TOS is caused by injury to the nerves in the brachial plexus.The most prominent symptom of the disorder is pain. Other symptoms include weakness and fatigue.3

Arterial TOS occurs on one side of the body. It affects patients of both genders and at any age, but often occurs in young people. Like true neurologic TOS, arterial TOS is rare and caused by a congenital anomaly. Symptoms can include sensitivity to cold in the hands and fingers, numbness or pain in the fingers, and finger ulcers (sores) or severe limb ischemia (inadequate blood circulation).3

Venous TOS is also a rare disorder that affects men and women equally.The exact cause of this type of TOS is unknown. ItJHI often develops suddenly, frequently following unusual, prolonged limb exertion.3

Traumatic TOS may be caused by traumatic or repetitive activities such as a motor vehicle accident or hyperextension injury (for example, after a person overextends an arm during exercise or while reaching for an object). Pain is the most common symptom of this TOS, and often occurs with tenderness. Paresthesias (an abnormal burning or prickling sensation generally felt in the hands, arms, legs, or feet), sensory loss, and weakness also occur. Certain body postures may exacerbate symptoms of the disorder.3

In chiropractic and physical therapy,TOS is often categorized based on the location of anatomical compression on the neurovascular bundle.There are a number of factors operating in four distinct anatomical locations, resulting in four distinct syndromes.These factors include: tight or hypertrophied muscles, ligaments, fibromuscular bands, or bony abnormalities in the thoracic outlet areaThese rigid osseous boundaries, strong muscles, and fascial structures are prime conditions associated with syndromes of impingement or compression.

The Four Syndromes

Zone 1.This area is bordered by the anterior scalene, medial scalene, an arch-like band of fascia between these two, the first rib, and Sibson's fascia (over the cupola at the apex of the lung).This opening can range in A-P width from 0.4 to 3.5 cm. Entrapment in this area typically involves a combination of joint dysfunction in the first costotransverse joint and adhesion or hypertonicity/spasm of the anterior and middle scalene muscles due to nerve root irritation, spondylosis, degenerative joint disease or facet irritation, resulting in anterior scalene syndrome. Some authors contend that the primary muscle involved in this syndrome is the anterior scalene muscle, and that the middle scalene muscle simply represents a limiting border for the compression.4

Causes and aggravating factors include scalene spasm secondary to trauma (i.e., whiplash), faulty posture (anterior head carriage), hypolordotic cervical spine, and upper chest breathing patterns.5

Of particular interest are the anatomical variants associated with anterior scalene syndrome.The subclavian vein lies anteromedial to the anterior scalene; the subclavian artery and brachial plexus run posterolateral to this muscle. A frequent variant has the subclavian artery and C8 nerve root piercing the anterior scalene (similar to the piriformis and sciatic nerve root variants), creating another potential entrapment site.

Zone 2 is bordered by the medial third of the clavicle, the costoclavicular ligament and the subclavicular muscle, the anterior third of the first rib, the upper margin of the scapula, and the anterior and medial scalene insertions. Narrowing of the space between the clavicle and the first rib leads to costoclavicular syndrome. This narrowing places increased pressure primarily on the subclavian artery and vein, and may also affect the brachial plexus.There is an increased incidence in 35- to 55-year-old women.6

Severe emphysema and other upper-chest breathing patterns, excessive muscular development, backward and downward thrust of the shoulders (as in carrying a heavy backpack) and postural changes (as in military posture) can cause abnormal lifting of the first rib or lowering of the clavicle, hence decreasing the claviculocostal volume. Improperly healed clavicular fractures, with increased callus formation, or exostoses of the clavicle or first rib can contribute to this syndrome, as can hypertrophy or spasm of the subclavius and muscles of the scalene group.

Zone 3 is bordered by the coracoid process, pectoralis minor, the first three ribs, and the humeral head. Compression of the neurovascular elements between the anterior aspect of the rib cage and the pectoralis minor muscle results in pectoralis minor syndome, aka hyperabduction syndrome, infraclavicular syndrome, hyperabduction syndrome, or Wright syndrome.5 Compression at this site produces neurological symptoms, rather than vascular.

This pattern is highly associated with poor work or postural habits, rather than faulty anatomy. Cash register operators, typists, computer operators, packers, and assembly line workers often suffer from TOS because of the awkward work posture and repetitive motion that produces continuous muscle tension.6 Volleyball, tennis, painting, mechanics, and other activities involving reaching above shoulder level with shoulder elevation and arm hyperabduction can induce the condition as well. Depression, fatigue, and low selfesteem postures and upper-chest breathing involving the pectoralis minor as an accessory muscle are also implicated. Drooped posture causes the distal end of the clavicle to descend and increases the traction effect the coracoid process has on the neurovascular bundle pathway.

Zone 4:This zone applies to cervical rib syndrome. When a rudimentary rib, or enlarged cervical transverse process is present at C7, the lowest brachial trunk or subclavian artery is caught between the rudimentary cervical rib and the clavicle.6

Less than one percent of the population has an extra rib at C7.7 Only 10 percent of those with an extra rib, however, have related symptoms.6 This condition may vary in size from a slight enlargement of the TVP up to a completely formed rib with attachments to the sternum and the first costal cartilage, or to the first thoracic rib.When it is incompletely formed, it is attached by a fibrous band.This condition increases the likelihood of developing TOS ten-fold. Even with this condition, there is usually a precipitating injury. Improperly healed rib fractures can contribute. Cervical spine exostoses may contribute to nerve root irritation and muscular spasm.

Symptoms:

TOS symptoms can be produced by a positional, intermittent compression of the brachial plexus, of the subclavian artery or vein, or of the vertebral artery. Entrapment of the nerves or vasculature in this area produces upper extremity pain, altered sensations, motor dysfunction, and vascular insufficiency.8

Ninety percent of patients with TOS complain of neurological signs of pain and paresthesias.9 Of these neurological signs, two types of patterns are common.10 The upper plexus compression pattern involves the roots of C5, C6, and C7-often with paresthesia into the radial nerve distribution, with sensory changes occurring primarily in the first three fingers, and muscle weakness or pain in the anterior chest, triceps, deltoids, and parascapular muscle areas, as well as down the outer arm to the extensor muscles of the forearm. Other symptoms may also include pain in the neck, face, mandible, and ear with occipital headaches, dizziness, vertigo, and blurred vision.

The other pattern, lower plexus compression, involves the roots of C8 and T I, often with paresthesia into the ulnar nerve distribution and sensory changes primarily in the fourth and fifth fingers," with muscle weakness or pain from the rhomboid and scapular muscles to the posterior axilla, down the ulnar distribution to the forearm involving the elbow, flexors of the wrist, and intrinsic muscles of the hand.12 Any vascular involvement should be examined, as this can lead to more serious consequences.

Ischemic symptoms include numbness, coldness, weakness, edema13 of the dorsum of the hand and base of the fingers primarily upon waking,11 and discoloration.ls Patients also have reported dropping objects and worsening of the symptoms when elevating the arm to chest level, as when driving a car or performing actions above the head.

Diagram I on p. 2 I summarizes the symptoms for the compression of specific structures.12

Clinical Findings and Physical Examination:

Anterior Scalene Syndrome:

*Fixation of the first costotransverse, cervical, and upper thoracic motion segment joints, hypertonicity, shortening, and tenderness to palpation of the anterior and medial scalene muscles; weakness of the upper trapezius muscle

*Positive radicular testing with pressure applied over the scalenes

*Positive Adson's position test (radial pulse decrease with ipsilateral neck rotation and extension with inhalation and arm extension and traction with wrist flexion)

*Positive Elevated Arm Stress Test (EAST). The patient is in the "stick-em-up" position for three minutes, alternately opening and closing hands (see Fig. 1). Patients with carpal tunnel syndrome will experience dysthesias of the fingers with this test, but without shoulder or arm pain.Testing needs to elicit significant characteristic symptoms; pulse decrease without symptoms is not sufficient to make a diagnosis.

*Compression of the subclavian artery can result in ischemia, decreased peripheral pulses, coolness, pallor, and possible cyanosis of the upper extremity. Auscultation of the anterior cervical triangle will often reveal a bruit, especially when the arm is held in abduction and extension.

*Compression of the brachial plexus in this syndrome can result in paresthesias, anesthesias, pain, weakness, and atrophy in the upper extremity.

*Ulinar nerve involvement produces symptoms in the medial forearm, medial hand, and the fourth and fifth fingers and may extend to the supraclavicular and infraclavicular fossa, the back of the neck, the rhomboid area, and the axilla.

*Radial nerve involvement will show symptoms in the lateral arm, forearm, and the dorsum of the thumb; the pain pattern can involve the neck, ear, mandible, upper chest, shoulder, and upper back.

*Due to the altered tension of the tissues on which the inferior cervical sympathetic ganglion lie, autonomie symptoms may result.

Costoclavicular Syndrome:

*Fixation of the sternoclavicular joint

*Scalene hypertonicity

*Positive modified Adson's (contralateral neck rotation).

*Positive Eden's test (see Fig. 2)

*Compression of the subclavian vein running anterior to the anterior scalene can result in swelling in the hands. Vascular symptoms, especially of the subclavian vein, dominate as compared to the predominance of neurological symptoms found in anterior scalene syndrome. Signs include tenderness, pain, coolness, pallor, diminished distal pulses, paresthesia, numbness, and edema in the fingers and dorsum of the hand.

Pectoralis Minor (Hyperabduction) Syndrome:

*Round-shouldered posture

*Positive shoulder compression test

*Positive hyperabduction (Wright's) test" (radial pulse obliteration with paresthesias in upper limb)(see Fig. 3)

*Positive EAST test

*Bilateral palpation of the stenoclavicular junction and acromioclavicular joint will usually demonstrate asymmetries

*Transient ischemia and edema may increase with hyperabducted positions

Cervical or Thoracic Rib Syndrome:

*Positive radiographs showing elongation of the transverse process of C7 (unilateral or bilateral). These enlargements can increase compression on the lower components of the cervical plexus and subclavian artery resulting in both paresthesias and diminished radial pulses.

*Positive contralateral Adson's testing and Alien's test (elbow flexed to 90° with shoulder abducted to 90° and external rotation with contralateral head rotation).

*Traction applied in a distal direction to the involved arm for several seconds may show a diminished radial pulse.

*Palpation of the supraclavicular fossa may demonstrate a prominence with deep palpation, eliciting symptoms.

Diagnosis:

Identifying TOS requires a thorough history and examination of the clinical presentation. It is important to differentiate TOS from other conditions such as carpal tunnel syndrome, cubital tunnel syndrome, shoulder tendonitis, bursitis, or impingement syndrome, fibromyalgia of the shoulder and neck muscles, radiculopathies, and cervical disc disease.

The possibility of double-crush syndrome (referring to the coexistence of dual cumulative compressive lesions along the course of a nerve) needs to be considered. Possible contributor sites are: upper cervical dyskinesia, cervical and thoracic DJD, cervical spondylosis or radiculopathy, carpal tunnel syndrome, and cubital tunnel syndrome.

Differentiating tests must include both peripheral and central provocative challenges. Examples of peripheral testing include: Tinel's test at the wrist and elbow, Wright's hyperabduction test, Phalen's test, carpal compression test, shoulder ROM, sensory and deep-tendon reflex. Examples of central tests are: brachial plexus tension test, Spurling's test, Adson's and modified Adson's tests, scalene compression test, first rib compression, doorbell testing, and Kemp's cervical spine compression.

Other possible contributing factors include hypothyroidism, diabetic neuropathy, pregnancy, and peripheral or obstructive vascular disease.

Trigger-point referrals (TrP) may display similar pain patterns as TOS14, but there will be no accompanying sensory loss with TrPs, i.e. TrP distribution for serratus posterior superior extends from beneath the scapula, spreading over the shoulder joint, and down into the arm onto the ulnar side of the wrist and the fourth and fifth fingers.The pectoralis minor muscle TrP in its distal pattern is also similar to the distribution of the radial and medial antebrachial cutaneous nerves.

Vascular, pulmonary, cardiac, connective tissue disorders, and esophageal disorders need to be considered in the differential diagnosis-in addition to multiple sclerosis, rotator cuff injuries, spinal cord neoplasms, Raynaud's disease, vasculitis, trauma, and Pancoast's tumour.

Imaging studies help identify cervical ribs and clavicular deformity. Referral out for color-flow duplex scanning, arteriograms, and venography may indicate etiologies of a vascular nature. Nerve conduction studies via nerve root stimulation and F-wave is the best diagnostic assessment for neurological symptoms of the syndrome.

The most common misdiagnosis for TOS is carpal tunnel syndrome. In contrast to TOS, which most commonly involves the lower two roots (C8 and Tl) with paresthesias either in the ulnar nerve or in the upper three nerve roots (5, 6 and 7) with paresthesias into the radial nerve, carpal tunnel syndrome involves a compression of the median nerve in the distal wrist.

Therapists approaching the symptom complex of TOS must also be aware of the multiple conditions within this syndrome.Thus, a patient may have concomitant TOS, ulnar nerve compression at the elbow, and carpal tunnel syndrome. A patient may also have scalene syndrome and pectoralis minor syndrome. When there are multiple compression sites, less pressure is required at each site to produce symptoms. Assessment of positions or movements that initiate or aggravate the patient's symptoms can help locate the lesion. Physical examination is fortunately the most informative differential.

Treatment:

Treatment for TOS would ideally be a synchronous blend of joint mobilization/manipulation, physical therapy modalities,17 home stretching exercises,18 patient education, and soft-tissue therapy.14,19

Involvement of the cervical spine, thoracic spine, shoulder girldle (involving glenohumeral, acromioclavicular, and sternoclavicular joints), elbow, and wrist dysfunctions/subluxations must be identified and corrected via manipulation or mobilization, since joint irritation can cause muscle spasm or hypertonicity.

In anterior scalene syndrome, the primary manipulation will first focus on costotransverse, cervical, and upper thoracic segment joints, as they are often fixated due to trauma (i.e., whiplash), faulty posture (anterior head carriage), hypolordotic cervical spine.5 In costoclavicular syndrome, one would focus on restoring the proper mechanics of the clavicle by adjusting sternoclavicular and acromioclavicular joints with an instrument (i.e. Activator) or using a drop-piece technique with the patient supine; using soft-tissue therapy to decrease the tension and restore the normal function of the subclavius muscle is also very important. On the contrary, treatment for pectoralis minor syndrome may involve more areas since this syndrome is highly associated with poor work or postural habits, rather than faulty anatomy. Postural correction using effective chiropractic techniques and procedures would help to reduce anterior head carriage and rounded shoulder, as well as restore normal cervical lordosis and proper biomechanics of the spine. One may also need to restore the biomechanics and stability20 of the scapula function to decrease the traction effect of the coracoid process on the neurovascular bundle pathway.

Physical modalities,17 such as laser or electrotherapy, may also be used to decrease fascial or joint inflammation and promote healing. In addition, proper breathing exercises may assist in correcting and maintaining postural correction and in reducing continuing strain on the accessory breathing muscles (i.e., scalenes, subclavius). Worksite and lifestyle environments need to be evaluated in terms of ergonomie suitability to the patient's capacities. Psychological/ emotional counseling may also be utilized in cases where poor self-image impacts posture.

Soft-tissue therapy, such as trigger-point therapy, to address problems with the pectoralis minor, scalenes, anterior serratus, and lower trapezius (for scapular stabilization),20 has been widely utilized in manual medicine to eliminate trigger point sensitivity in the associated muscles. Other myofascial release techniques are also used to release fascial adhesion in chronic cases. However, it is important to select the appropriate technique for patient depending on the patient's tolerance and the nature of the soft-tissue lesion. Also, the selected therapy should target strengthening and/or lengthening the appropriate muscle group(s) and ligaments and myofascial tissues.To achieve the best results, practitioners may need to apply a wide range of techniques, including trigger-point therapy, straincounterstrain, myofascial release, post-isometric relaxation, and post-facilitation stretching. One of the more recent advanced manual neuromuscular soft-tissue therapies is called Trigenics.21

Trigenics protocols play a role in neuromuscular facilitation in balancing and re-educating the firing pattern of the muscles.These protocols are highly versatile and allow for correction of a wide variety of myofascial lesions, ranging from simple acute sprain and strain22,24 to fibromyalgia25 and myofascial lesions secondary to neurological conditions such as cerebral palsy.26

Long-term success of conservative management depends on patient compliance with a home exercise program and behavior modification at home and at work. Surgical decompression should be reserved for patients who fail to improve with conservative management.16

Summary:

TOS is most frequently caused by poor or strenuous posture, especially thoracic hyperkyphosis and stooped posture; hyperextension injuries to the neck such as whiplash injuries; and repetitive stress at the workplace.

Prevalence is three times as frequent among females as it is among males. Predisposing factors include females of middle age with poorly developed axial and shoulder girdle musculature, and vigorous occupations or weight lifting that result in an increase in musculature.27 Undue tightness of the scalene muscles and tight pectoral muscles that have become chronically contracted due to the weight of heavy breasts in some women has also been suggested as an etiological factor by Phillips and Grieve.28 A high incidence has also been noted in those who make their livings as cashiers, overhead stockers, musicians, typists, packers, and assembly-line workers.29 Other contributors are pregnancy, inappropriate exercise, hyperventilation syndrome, carrying heavy shoulder bags or briefcases, and cervical exostoses. Many TOS patients habitually sleep with the arms hyperabducted.15

The costoclavicular syndrome and anterior scalene syndrome have been considered the most prevalent compression syndromes.30 The four syndromes of the thoracic outlet can be sub-classified by the symptoms of the structure compressed: artery, vein, and nerve. A careful history and thorough physical examination are the most important components in establishing the diagnosis of TOS. The use of radiographie and laboratory tests, when indicated, can improve the diagnostic yield. Provocative positional maneuvers must be evaluated for their vascular and, more important, for their neurologic response.These maneuvers do not "make" the diagnosis, but they can be a useful adjunct for confirming the diagnosis.31

The role of all treatments is to increase the volume of the lesional "tunnel" by addressing the soft and hard tissues surrounding or influencing all sides of the involved space and affecting the enclosed neurovascular tissues. The authors propose the use ofTrigenics therapy as a treatment option for TOS. It is not the goal of this paper, however, to discuss the history, theory, and full application of this therapy. Whatever the choice of therapy, astute skill and perception of the practitioner are required to conceptualize the particular characteristics of each patient's condition to focus therapeutic efforts appropriately. Treatment addressing only the neurovascular structures may produce temporary relief of symptoms, but postural correction cannot be maintained without correction of the associated muscle imbalance in the cervicoscapular region." Proper treatment requires accurate understanding of the postural factors involved. Most recent programs consider evaluation of joint mobility and muscular imbalance essential.33 Conservative therapy with the aim of restoring the function of the upper thoracic aperture is to be recommended, and longterm follow-up is advisable.18

References:

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21. Hooper K. Advanced Neuromuscular Medicine for Soft-Tissue Conditions and Athletic Enhancement: Gluteus Medius Strain in a Competitive Triathlete -A Case Study. Dynamic Chiropractic, 2 I (I 7), August 16, 2003

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23. Austin A. Trigenics theory. Toronto: The Trigenics Institute of Neuromuscular Medicine, 2002.

24. Pisarek S. Acute Inversion Ankle Reflexogenic Strain. Canadian Chiropractor, 7 (4). September 2002

25. Guenette C. Soft Tissue Approach to Fibromyalgia: A new treatment protocol combining chiropractic with theTrigenics technique. Canadian Chiropractor, 8(1), February 2003

26. McAllister P. Cerebral Palsy- The Trigenics technique is applied to an I I-year-old girl with cerebral palsy to improve her strength and range of motion. Canadian Chiropractor Magazine: May 2003, 8(3); pp 18-23.

27. Young HA, Hardy, DG. "Thoracic Outlet Syndrome"; Br J Hasp Medicine; 1983, 29: p. 457-9

28. Phillips H., Grieve GP. Modern Manual Therapy of the Vertebral Column; NY: Churchill Livingstone, 1986; p.359-64, 368.

29. Sallston J, Schmidt H."Cervicobrachial Disorders in Certain Occupations with Special Reference to Compression in the Thoracic Spine"; AM j lnd Medicine; 1984, pp.645-52.

30. Winsor T, Winsor D, Mikail A, Sibley AE. Thoracic outlet syndromes-application of microcirculation techniques and clinical review. Angiology. 1989 Sep;40(9):773-82.

31. Rayan, GM.Thoracic Outlet Syndrome.] of Shoulder and Elbow Surgery. 1998 juI, 7(4), pp. 44051

32. Novak CB. Thoracic outlet syndrome, din Plast Surg. 2003 Apr;30(2):pp. 175-88

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BY KIM McKENZIE, ND, DC, GENE LIN, DC, AND SHAI TAMIR, DC

The authors can be contacted as follows:

Kim McKenzie, ND, DC, 2826 Dundas Street West, Toronto, Ontario, Canada M6P IV7, 416/763-3211

Gene Lin, DC, 26 Crayford Drive, Toronto, Ontario, Canada M IW 366, 416/880-5350

Shai Tamir, DC, Wellington Chiropractic Centre, #2297 Wellington Street East, Aurora, Ontario, Canada L4G IG3, 905/727-7463

Copyright American Chiropractic Association Jan 2004
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