The Effectiveness of Diagnosis and Treatment of Thoracic Outlet Syndrome

In today's hectic society it becomes a great disadvantage to individuals when they develop pain and discomfort that decreases their ability to function efficiently. Thoracic Outlet Syndrome (TOS) is a condition that causes pain in the upper extremity, typically extending along the inner aspect of the arm and hand. Other symptoms include weakness, numbness and tingling in the upper extremity. A neurovascular bundle that consists of the brachial plexus, subclavian artery and vein travels from the neck into the arm. TOS symptoms result when the nerves or blood vessels are compressed by the surrounding anatomical structures. In performing this research study, our team would like to improve awareness of TOS to all health care professionals as an entrapment neuropathy and differential diagnosis to neck pain with referred pain. We would also like to bring osteopathic medicine, physical therapy and other paradigms of musculoskeletal manual medicine/therapy together to develop a standardized and valid approach to the diagnosis and treatment of TOS which is not currently available.

There are multiple possible causes of TOS, majority of which results in anatomic restrictions. These possible causes include trauma to the shoulder girdle and more commonly postural disturbances. Individuals with TOS often sit at a computer or desk for an extended period of time for work or school. They develop rounded shoulders and a forward head carriage which changes the length and tone of certain muscles and the relationship of structures in relation to the neurovascular bundle. The anatomic disturbances that contribute and is of the greatest interest to osteopathy includes hypertonicity of the anterior and middle scalene muscles in the neck, hypertonicity of the pectorialis muscle from the upper extremity to the 3-5th ribs, somatic dysfunctions of the clavicle, upper thoracic region and ribs (especially the first rib) (Ward, 2003).

TOS is often the resulting diagnosis after elimination of other possible conditions that cause similar symptoms. These other possible conditions include disc herniations, osteoarthritis, tumors and nerve entrapment syndromes such as carpal tunnel syndrome. Currently discrepancies exist between clinicians about the correct approaches to diagnosis and treatment of TOS. Today's technological advancements can help provide more information about the patient's anatomy, however none can be used for diagnosis alone. MRIs are usually best used for confirmation for the evaluation of the region of interest, however in TOS, findings are frequently inconclusive. One reason for this may be the difficulty to evaluate the extent of a muscle spasm or rib somatic dysfunction and the degree to which it is compressing a nerve structure. (Koknel 2005). X-rays are used to eliminate extra ribs in the cervical region as a cause for symptoms. Anomalous cervical ribs are found in 0.17% to 0.74% each year, however, only 10% of individuals experience TOS symptoms and the onset of these symptoms often relates to cervical spine trauma (Novak, Mackinnon, 2002). The diagnosis of TOS remains to be best based on the patient's subjective complaints, physical examination and the exclusion of other pathologies (Novak, Mackinnon, 2002). Clinical assessment of TOS is best achieved by reproduction of symptoms with compression and special orthopaedic provocative tests that re-produces symptoms based on patient position (Koknel, 2005).

These orthopedic special tests will include:

Wright Test (See picture appendix 2): Wright Test, or Hyperabduction Test, is done by bringing the arm into full abduction with the shoulder externally rotated and the elbow extended while monitoring the radial pulse throughout (Magee DJ, 2008). If there is a decrease or absence of pulse the test is positive showing that axillary artery is compressed by either the pectoralis minor muscle or the coracoid process. (Köknel Talu G, 2005)