Clinics Ii Midterm - Tos

Front 1

Boundaries of Thoracic Inlet

Back 1

• scalenus anterior + clavicle - anteriorly
• scalenus medius & posterior - posteriorly
• 1st rib – inferiorly

Front 2

Contents of Thoracic Inlet

Back 2

• brachial plexus
• subclavian artery
• NOT subclavian vein

Front 3

Types of TOS

Back 3

• Neurologic
• Arterial
• Venous

Front 4

TOS - Statistics

Back 4

• Neurologic type
- most common
- accounts for 95% of cases of TOS
- the lower 2 roots of the brachial plexus C8 & T1 are most commonly involved (ie. in 90% of cases)

• Venous type
- accounts for 3-4% of cases of TOS

• Arterial type
- least common
- accounts for only 1-2% of all cases of TOS

Front 5

TOS - Clinical Presentation

Back 5

• neurological TOS 3.5 x more common in females
• venous TOS > in males
• arterial TOS - no gender bias
• usually occurs between 20-50 years of ageaverage
• age of patients who have arterial symptoms is 10 years older than the average age of patients with neurological or venous symptoms
• swimmers, water polo players, baseball & tennis (ie. activities which place the shoulder in the extreme ranges of abduction & external rotation)

Front 6

TOS - Areas of Potential Compression

Back 6

• Scalene Triangle
- arterial & neurogenic complaints but not venous
- tight scalenes, scar tissue around the scalenes, muscle spasm, muscle hypertrophy, anomalous fibromuscular bands or presence of a cervical or extra rib
- AP dimensions of the scalene triangle are reduced in cervical extension or
ipsilateral rotation (Adson’s test)

• Costoclavicular Interval
- between the clavicle (superiorly) & the 1st rib (inferiorly)
- most often due to poor posture (eg. scapular depression) or carrying heavy objects

• Infraclavicular Region
- beneath the coracoid process deep to pectoralis minor
- pectoralis minor acts like a sling + coracoid process moves down with abduction exaggerating the sling effect
- compression occurs when the arm is raised into full abduction & ER (Roos test)

Front 7

Neurological TOS - Signs & Symptoms

Back 7

• diffuse aching pain and/or paraesthesia radiating from the neck down the arm particularly the medial aspect of the arm, forearm, D4 & D5 - made worse by elevation of the upper limbs
• P & N’s and/or numbness especially in the am but may awaken the patient at night - begins peripherally & progresses centrally
• other neurological symptoms may include headache, loss of hand dexterity, and cold intolerance
• UE may feel heavy or weak after activity d/t pressure on the motor nerves - atrophy rare
• limb may tire easily
• may be key muscle weakness if the lower trunk of the brachial plexus is involved
• muscle atrophy
• altered sensory perception
• signs of sympathetic involvement
• +ve ULNT most commonly involving the ulnar nerve bias

Front 8

Arterial TOS - Signs & Symptoms

Back 8

• rapid fatigue & numbness of entire arm during overhead exercise
• ↓ed temperature + pulse in affected hand
• pallor
• coolness of the affected side
• lower BP on the affected side (a reliable indicator of arterial involvement)
• claudication occurs with arterial compromise
• may or may not be +ve provocative TOS tests

Front 9

Venous TOS - Signs & Symptoms

Back 9

• cold, swollen, glossy, discoloured UE after exercise
• TOP over the course of the vein
• edema
• may be distended superficial veins of the shoulder & chest

Front 10

Infraclavicular Region - Boundaries

Back 10

• beneath the coracoid process deep to pectoralis minor

Front 11

Costclavicular Interval - Boundaries

Back 11

• between the clavicle (superiorly) & the 1st rib (inferiorly)

Front 12

Roos Test

Back 12

• patient abducts arms to 90 degrees in full GH ER with elbows slightly beyond the frontal plane
• patient opens & closes his/her fists slowly for 3 minutes or until his/her symptoms reproduced
• +ve findings = ischaemic pain, heaviness or profound weakness of the arm or numbness & tingling of the hand

Front 13

Adson's Test

Back 13

• most common method of vascular testing
• therapist locates the radial pulse - patient’s head is then rotated to face the shoulder being tested while the therapist ER & extends the patient’s shoulder – patient then asked to take a deep breath

Front 14

Halstead Manouvre

Back 14

• palpate radial pulse & applies a downward traction on the UE while the patient’s neck is hyperextended & his/her head is rotated to the opposite side

Front 15

Shoulder Girdle Passive Elevation Test

Back 15

• examiner grasps the patient’s arms from behind & passively shrugs the patient’s shoulders
• hold x 30 seconds
• release phenomenon - symptoms return upon cessation

Front 16

Costoclavicular Maneuver

Back 16

• radial pulse palpated
• depress scapula & extend GHJ
• +ve test = absence of pulse & reproduction of patient’s symptoms

Front 17

Allen Test

Back 17

• 90° elbow flexion
• GHJ ABD & full ER
• patient asked to rotate his/her head away from the test side

Front 18

Vascular Tests

Back 18

• provocative vascular tests may or may not be positive in TOS - poor validity & reliability in these tests
• to be +ve, these tests must not only obliterate the pulse, but also reproduce the patient’s symptoms

Front 19

TOS - Treatment

Back 19

• patient education
• nerve gliding
• breathing exercises
• stretching
• manual mobilization
• relaxation exercises
• modalities
• taping
• medical management
• surgical management

Front 20

Treatment - Patient Education

Back 20

• postural correction
• avoidance of repetitive overhead activities & lifting
• stress avoidance
• avoidance of asymmetrical load
• sleep position
- use of a body pillow to support the affected arm in front of the body
- avoid sleeping with the arms overhead
• ergonomic education
• job modification

Front 21

Treatment - Nerve Gliding

Back 21

• used to glide the brachial plexus through the TO to minimize scarring & pressure
• improve neural mobility through neck/shoulder movement
• performed in pain free range
• mobilize tendons in a tight space
• decongestion of the area

Front 22

Treatment - Breathing

Back 22

• teach lateral costal breathing versus apical breathing

Front 23

Treatment - Stretching

Back 23

• stretch truly short muscles
- scalenes
- pectoralis minor
- sub-occipitals
- erector spinae

Front 24

Treatment - Strengthening

Back 24

• scapular stabilizers
• abdominals
• short neck flexors

Front 25

Treatment - Manual Mobilzization

Back 25

• 1st rib
• C-T junction
• T-Spine
• SC joint
• Scapulothoracic 'joint'
• AC joint

Front 26

Treatment - Taping

Back 26

• correction of postural problems (i.e., drooped scapula)