01 96-601 1 /79/0102-0089$02.00/0 THE JOURNALOF ORTHOPAEDIC AND SPORTSPHYSICALTHERAPY Copyright O 1979 by The Orthopaedic and Sports Medicine Sections 01 the American Physical Therapy Association

The Thoracic Outlet Syndrome: A Protocol of Treatment *

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KENNETH F. SMITH,? ,$ BS, PT

A protocol of treatment for the physical therapy management of the thoracic outlet syndrome has been established at Amsterdam Memorial Hospital, Amsterdam, New York. Certain orthopaedic manual therapy procedures are utilized to increase the mobility of specific areas of the patient's shoulder girdle, upper thorax, and if indicated, the cervical and upper thoracic spine. Previous training in orthopedic manual therapy is a prerequisite to employing this approach to the treatment of the thoracic outlet syndrome. A total of eight anatomical structures are involved. This particular regime of manual therapy plus postural improvement, corrective exercises, improved body mechanics, and other procedures relating to the patient's activities of daily living have proven to be an effective method to relieve the signs and symptoms produced by this musculoskeletal entity. Paraesthesiae and numbness were the predominant symptoms of the patients that underwent treatment. The patients ranged in age from 2 7-60 years.

The neurovascular structures that are involved in this compression syndrome are the lower cords of the brachial plexus and the subclavian artery and vein. The signs and symptoms encountered in the upper extremity may include paraesthesia, numbness, pain, edema, muscle weakness, claudication, discoloration, temperature and tropic changes, ulceration, gangrene, and, in some cases, Raynaud's phenomenon. The symptomatology varies according to the particular structures that are being compressed or irritated as well as the frequency, duration, and degree of compression. The various causes of thoracic outlet syndrome (TOS) are well documented,'-7 e.g., cervical rib, fibrous or muscular band, hypertrophied scalene muscles, postural abnormalities, to mention only a few. The primary purpose of this paper is to present a program of treatment management. The pathology, signs, and symptoms of the specific aspects of the TOS

have been described in the literature over a number of years.'-7 Lord and Rosati' believe that the costoclavicular area is a major source of difficulty in the TOS, even when diagnostic studies appear to indicate otherwise. Therefore, a major part of this treatment approach is directed toward this area. The treatment concept is based upon the following: as the neurovascular structures are compressed between the 1st rib and clavicle, the pressure is relieved by first, restoring (or increasing) the accessory joint movement at the sternoclavicular and acromioclavicular joints; second, increasing the mobility of the 1st and 2nd ribs; and third, relieving muscle tension in the shoulder girdle musculature and restoring any loss of muscle elasticity. Subsequently, the clavicle (or "roof" of the compression compartment) and the 1st rib (the "floor" of the compartment) are given greater separation. The costoclavicular space is enlarged and the compression of the neurovascular bundle is reduced or eliminated. Although the separation of these boney structures is minimal, this increase in space is sufficient to reduce significantly the pressure exerted upon the nerve or vascular structures. Postural improvement, corrective exercises, and certain activities of daily living procedures contribute to this compression release.

* This protocol of treatment for the physical therapy management of the thoracic outlet syndrome was presented at the Humera Society Meeting in Bermuda on April 23. 1976 and as a two-way radio conference for The Department of Postgraduate Medicine. Albany Medical College. on April 13 and 14, 1977. From the Amsterdam Memorial Hospital. Upper Market Street, Amsterdam. New York 1201 0. f Administrative Physical Therapist.

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EXAMINATION

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All therapy is preceded by a clarifying examination of the patient by the physical therapist.~.2.4. 7-10 A thorough history is taken followed by a physical examination that includes the following tests: 1) Adson's maneuver: for compression occurring in the interscalene space. 2) Costoclavicular maneuver: for compression occurring in the costoclavicular space. 3) Hyperextension maneuver: for compression occurring from the pectoralis minor tendon, subclavius muscle and/or costocoracoid membrane or ligament. 4 ) Hyperabduction maneuver: same as the hyperextension maneuver, but considered by some to be less accurate in incriminating the upper thoracic musculature due to the backward movement of the clavicle upon upper extremity elevation. The examination should also include sensory and manual muscle testing, differential palpation, check for muscle wasting, notation of upper extremity temperature, color, or presence of edema, oscillometric studies (if indicated), observation of breathing pattern, examination for postural defects, musculoskeletal deformity, tropic changes, release and compression phenomena, carpal-tunnel syndrome, articular and periarticular disorders of the affected upper extremity and shoulder girdle, shoulder-hand syndrome, and a cervical and upper thoracic spine examination (foramina1 compression test, mobility, etc.). The author has also found the following maneuvers diagnostically useful in eliciting the patient's symptoms and/or signs: the patient is placed in a sitting position. With the arm passively supported in 80-90 degrees of shoulder abduction and elbow flexion with the forearm parallel to the floor, the medial one-half of the clavicle is passively depressed in the caudal direction. Only a moderate amount of pressure is exerted. The position is held for 15-20 seconds. The maneuver should also be performed with the patient taking and holding a deep breath. This test is designed to eliminate or minimize the stress placed upon the structures of the shoulder joint and cervical spine during the test maneuver. Va:;ations of this maneuver can be performed, e.g., depressing the clavicle first followed by the passive movement of the arm into the test position; however, the examiner must first rule out a shoulder lesion as the possible cause of the patient's symptom^.^ The first

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four maneuvers and the author's maneuvers are also performed on the unaffected side and the results compared. The author prefers to test the uninvolved side first. The various diagnostic maneuvers are helpful, but not infallible. To help differentiate between a neurovascular compression syndrome of the shoulder girdle and a cervical lesion, the following maneuvers are performed to eliminate, diminish, or change the patient's symptoms: 1) if compression within the shoulder girdle is suspected, passively elevate the shoulder girdle in the sitting position for 2030 seconds; and 2) if cervical radiculopathy is suspected, perform positional distraction in conjunction with manual traction. Possibly 30-35 pounds of traction may be required. If both of these maneuvers are negative (no relief of symptoms or change, e.g., numbness changing to pins and needles-release phenomena) and a thorough examination of the cervical and upper thoracic spine has been completed, an examination is performed for an articular or periarticular disorder of the shoulder girdle and distal joints. Cyriax' method of soft tissue diagnosis is most helpful in determining the existence of specific articular and periarticular lesion^.^ The results of the referring physician's examination can also be useful diagnostic information (e.g., roentgenograms, electromyography and nerve conduction studies, plethysmograms, myelograms, auscultation, etc.).

TREATMENT MANAGEMENT The physical therapy approach to the treatment of the TOS consists of three aspects of management.

Posture The first aspect is correction of postural faults and poor body mechanics that may be causing or contributing to neurovascular compression or irritation. For example, a common postural fault that can aggrevate this condition is the sagging or dropping of the shoulders; in other words, the round shouldered, slouched position. A forward head can indicate excessive tension in the scalene muscles. The patient must develop a greater awareness of his corrected posture. Initially, a new postural attitude is frequently uncomfortable. Constant reminders and encouragement by members of the family, therapist, and physician are essential.

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THORACIC OUTLET SYNDROME

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Orthopaedic Manual Therapy The second aspect of the treatment is orthopaedic manual therapy. The manual therapy increases the mobility of the shoulder girdle and the 1st and 2nd ribs on the affected side. The shoulder girdle and the 1st and 2nd ribs on the unaffected side also are treated in order to make postural adjustments easier from the kinesthetic standpoint. Greater attention, of course, is given to the affected side. The manual therapy consists of joint mobilization, soft tissue stretching and articulation, massage, and mobilization exercises. The anatomical structures involved are the sternoclavicular and acromioclavicular joints, scalene musculature, 1st and 2nd ribs, shoulder girdle musculature, and cervical and upper thoracic spine and musculature. The mobilization is comprised of the following seven steps. The first step is mobilization of the sternoclavicular joint.' This passive movement is an anteroposterior shear of the clavicle upon the sternum in a somewhat vertical plane (Fig. 1). This procedure is followed by mobilization of the acromioclavicular joint that is an anteroposterior shear of the clavicle upon the acromion in a somewhat horizontal plane. Caution must be shown not to create laxity at these joints by excessive articulation. The second step is passive stretching of the scalene and pectoral muscles, and if indicated, massage of the scalene muscles.73" Stretching

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of the scalene muscles is an important preliminary step to increasing the mobility of the 1st and 2nd ribs (Fig. 2). Excessive tension in the scalene muscles can result in elevation of the 1st rib, thus reducing the size of the costoclavicular space. If the nerve compression is occurring in the interscalene triangle, the patient's symptoms can be diminished at times by restoring or improving the elasticity of the scalene muscles, especially if they have been in a guarding position for an extended period of time. Caution is to be demonstrated in performing this procedure. The muscle stretching should always be done in a slow, gradual manner. Stretching of the scalene muscles should not be performed if there is an irritation of the brachial plexus in which traction on the plexus causes pain. A gentle kneading massage of the scalene muscles can also be done if there is no brachial plexus or nerve root irritation. If necessary, deep sustained pressure over the belly of the muscles can be used to induce relaxation. The pectoral muscles are the second group of muscles to be stretched (Figs. 3 and 4). The third step is scapula mobilization.'. ". l 2 This includes dorsal (away from the thorax), cephalad, caudal, medial, lateral, and rotary movements of the scapula (Figs. 5 and 6). The fourth step is 1st and 2nd rib articulation with the emphasis upon the 1st rib (Fig. 7)."* l 3 Figure 7 is posterior articulation with the cervical column stabilized through facet opposition and

Fig. 1. Mobilization of the sternoclavicular joint. The therapist is grasping the medial third of the clavicle.

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Fig. 2. Stretching of the scalene muscles. The Therapist's right hand is stabilizing the patient's shoulder.

Fig. 3. Stretching of the pectoral muscles and fascia. Some counterpressure is applied by the therapist's right hand on the belly of the pectoralis major.

ligamentous tension locking. Pressure is directed caudally and centrally over the angle of the rib. Springing of the 1st and 2nd ribs is also performed which creates a separational stress at the costovertebral joints (Fig. 8). The posterior articulation is followed by anterior articulation of the 1st and 2nd ribs with the pressure directed caudally against the sternocostal insertion of the Ist rib and the upper border of the 2nd rib (Fig. 9). The fifth step is massage of the shoulder girdle

musculature. A deep kneading massage is given to those muscles that have lost their elasticity due to muscle guarding and/or emotional tension. The petrissage is preceded and followed by an effleurage to improve venous and lymphatic circulation and to relax the patient. With the more emotionally sensitive patient, local heating may precede the massage (e.g., infrared radiation or the use of a hydrocollator pack). The sixth step is passive scapula-thoracic flexibility exercises (Figs. 10 and 11)." Complete

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THORACIC OUTLET SYNDROME

Fig. 4. An exercise to stretch tight pectoral muscles and fascia. The patient faces a corner of a wall and leans his body toward the corner without moving his hands or forearms on the wall.

Fig. 5 . Mobilization of the scapula in the cephalad, caudal, medial, and lateral directions.

relaxation of the patient during these passive movements is essential. Mobilization techniques other than those described may be used to accomplish the treatment objective. The author varies the technique according to the individual needs of the patient. During certain mobilization procedures, it is not unusual to evoke the patient's symptoms, especially in the beginning of the treatment program. However, one must stop short of reproducing a pain symptom.

The seventh step may or may not be necessary. This last step is the treatment of the cervical lesion, if indicated (e.g., apophyseal joint dysfunction, disc protrusion, spondylosis, etc.). A cervical lesion(s) could irritate the nerve supply to the scalene, subclavius, and pectoralis major and minor muscles, resulting in increased muscle tension, loss of muscle elasticity, possible shortening of the soft tissue, and reduction in size of the interscalene or costoclavicular space. As a result, the TOS signs and symptoms could

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be secondary to the cervical lesion. The patient's signs and symptoms could also be caused by pathology involving both areas. Physical therapy treatment to the cervical spine would include the

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use of heat (or possibly cold), adjustive or postional distraction, mechanical or manual traction, soft tissue stretching and articulation, spinal joint mobilization, and/or massage. The type of cervical lesion will dictate the treatment protocol to follow, which has been determined through a thorough clarifying examination. With the emotionally sensitive patient, the physician prescribed use of muscle relaxants or tranquilizers to reduce nervous and muscular tension is sometimes helpful during the period of time the patient is receiving his manual therapy treatments. The patient should be instructed to take his medication approximately one hour before receiving his treatment.

Home Program

Fig. 6. Rotary movement of the scapula upon the chest wall.

The third aspect of therapy management is the home program. Exercises for specific shoulder girdle muscles and/or the upper trunk (and possibly the lower trunk) are given only when there is evidence of a musculoskeletal defect due to a postural fault, muscle weakness, or muscle tightness. However, all patients are instructed in a shoulder girdle circumduction exercise (in otherwords, "rolling" the shoulders in as large a circle as possible). Instruction in "shoulder shrugs" as a primary exercise is not given. Very seldom do you find weakness in the trapezius and levator scapulae muscles. By exercising the scapular elevators, you improve the total efficiency of these muscles, not only their ability to contract, but also their ability to relax. Exercise

Fig. 7 . Posterior articulation of the 1st and 2nd ribs on the right side with the cervical column locked. The therapist's leff hand is maintaining the patient's cervical spine in leff side flexion and right rotation. (Each rib is done separately.)

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THORACIC OUTLET SYNDROME

Fig. 8. Springing of the 1st and 2nd ribs creating a separational stress at the costovertebral joints. (Each rib is done separately.)

conditions a muscle to relax more completely; therefore, at rest, the position of the clavicle in relation to the 1st rib is not altered by the shoul~ the costoder shrug e ~ e r c i s e .Consequently, clavicular space is not increased in size. The scapulae elevators are incorporated into the shoulder circumduction exercise. To reiterate, the treatment objective is to 1) enhance the overall mobility of the shoulder girdle by restoring any loss of accessory joint movement with passive mobilization techniques, 2) improve muscle efficiency with active exercises and massage, and 3) change postural habits and body mechanics that exacerbate the patient's signs and symptoms. Exercise and posture instructions at home and at work are essential to the success of this program. The patient should be given instructions related to occupational, recreational, and sleeping habits which include the following: 1) When working or relaxing, the patient should avoid the round shouldered, slouched position. Sagging or drooping of the shoulders

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can contribute to neurovascular compression. The patient should always maintain the normal thoracic curve (in otherwords, stand or sit tall); however, he must not overcompensate by keeping his upper body tense with his scapulae hyperadducted. If the patient's resting posture exhibits a forward (or "poked") head, he should be shown how to maintain correct posture by keeping his chin tucked in. 2) The patient should not carry heavy objects (e.g., a heavy shopping bag) in the hand (or arm) or slung over the shoulder on the affected side. If carrying a heavy object on the involved side is unavoidable, he should keep his shoulder elevated (shrugged) while carrying the object. The patient should also avoid physically stressful tasks that require pulling, pushing, or lifting with the affected arm. 3) Modification of sleeping habits is indicated if there is night discomfort: If the patient's condition is aggravated while sleeping, instruct him to change sides of the bed with his spouse. This arrangement may alter his sleeping posture and provide symptomatic relief. If shoulder abduction beyond 90 degrees aggrevates his condition, gauze tied to the patient's wrist and attached to the foot of the bed is sometimes helpful (allowing arm movement as hiah - as the chest)- or ~. i n n i n- a the sleeve of the pajama arm to the pajama leg. The patient should avoid sleeping on the affected side and in the prone-lying position. With the head on a pillow (especially a thick pillow), the cervical spine in the prone position is placed in forced rotation and hyperextension. If the patient's bed pillow is foam rubber, he should replace it with a down-filled pillow. 4 ) If indicated and if possible, the patient is to modify occupational postural habits and body mechanics which precipitate or exacerbate his signs and symptoms. 5) For female patients, bra straps should not be tight and should be stretch straps. For the woman with pendulous breasts, a strapless longline bra may help diminish the patient's signs and symptoms. 6) The patient is to avoid physical activities that result in hard or rapid breathing. These activities may recruit the accessory breathing muscles (the scalene) which elevate the 1 st rib. 7) The patient should try to avoid emotionally stressful situations. Muscular tension in the shoulder girdle musculature can contribute to a worsening of the patient's symptomatology. 8) The patient should not undertake strenuous

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Fig. 9. Anterior articulation of the 1st and 2nd ribs. (Each rib is done separately.)

Fig. 1 0. Scapula-thoracic flexibility exercise that consists of a passive circular movement.

physical tasks without adequate rest periods. Excessive fatigue from a work or recreational activity may result in poor posture and an aggravation of the condition. 9) If the automobile shoulder strap crosses the clavicle on the affected side, the patient must not draw the strap too snugly. 10) The patient should avoid any activity that results in backward bending of the head or elevation of the affected arm over the head. 11) Whenever the patient is relaxing in the sitting position, instruct him to rest the affected

arm on a chair armrest or pillow. The arm should be positioned below shoulder level. 12) If the patient has an acute episode of his symptoms, instruct him to pull his shoulders up into the shoulder shrug position as far as possible and hold them in this position for 30-60 seconds. The head should be kept in a neutral position (facing straight forward), not tilted backwards or pushed forward. If necessary, instruct the patient to a) lie in the back-lying position with his head placed on 3-4 folded towels and side bent tdward the affected side; b) with the arms

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Fig. 1 1 . Scapula-thoracic flexibility exercise that is also a ~ a s s i v ecircular movement.

slightly abducted and the elbows slightly flexed, place one folded towel under the affected upper arm and 3-4 folded towels under the lower forearm and hand; c ) partially shrug both shoulders; and d) relax completely. At times, having the patient rest his hands on his upper chest or abdomen provides greater symptomatic relief. A bed pillow under the knees is also helpful. 13) If an acute episode occurs in public, instruct the patient to roll his shoulders a few times, straighten his upper (thoracic) spine, and place the hand of the affected arm in his coat pocket or the front pocket of his trousers (or slacks) and relax the arm.

into the treatment program after 5-1 0 sessions. The length of each treatment session will vary according to the therapist's data base and reevaluation of the patient. Examples of treatment variability include patients that require more soft tissue treatment than others and cases in which the TOS exists bilaterally. The treatment time will vary from %-I hour. Upon completion of the treatment program (8-1 4 treatments), the therapist again performs the previously mentioned test maneuvers for the TOS and compares results.

Frequency and Duration of Treatment

A 36-year-old woman was seen in our facility complaining of a 3 year history of numbness (daytime and nocturnal) preceded by tingling in all five digits of the right hand, a feeling of "pressure" in the right forearm, and muscle soreness in the right upper extremity with activity. The patient also complained of coolness in the tips of all digits and episodes of swelling in the hand. She found it difficult to pursue her profession as a beautician. On physical examination Adson's maneuver was negative. The costoclavicular maneuver elicited paraesthesia in all five digits and markedly diminished the radial pulse. Upon hyperextension and hyperabduction, the paraesthesia was again evoked but was less pronounced than in the costoclavicular test and the radial pulse was only slightly dampened. The author's ma-

The patient should be seen daily for the first week and then three times per week for the next 1-3 weeks for a maximum of 8-1 4 treatments. If you do not achieve significant results after 1214 treatments, physical therapy is not the answer in that particular case of TOS. A neurological and/or surgical consultation should then be considered. If it is diagnostically confirmed that the patient's signs and symptoms are strictly the result of the TOS and not secondary to a cervical lesion, all treatment is directed to the shoulder girdle and the 1st and 2nd ribs. However, if a cervical lesion is contributing to the patient's symptomatology but to a lesser degree (in otherwords, more than one lesion exists), treatment of the cervical condition should be incorporated

Case Study

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diminished. Arm soreness improved. The coldness of all digits was infrequently experienced. The hand no longer became edematous. Although the patient was not completely asymptomatic, she was quite satisfied with the therapy results. Her residual symptomatology was not a significant discomfort factor. The patient has reported no regression in her condition since the termination of her therapy 8 months ago.

neuver elicited paraesthesia in the tips of all digits, especially the little finger, and a "pulling" sensation in the upper arm. Testing of the opposite side evoked identical symptoms, but the paraesthesia was less intense and less area was involved. There was a loss of mobility in the shoulder girdle bilaterally and impaired accessory movement in the sternoclavicular and acromioclavicular joints on the right side. The shoulders were somewhat rounded. Muscle strength, skin temperature, and color were uneffected. Examination of the cervical and thoracic spine and the shoulder, elbow, wrist, and finger joints revealed no evidence of an articular or periarticular lesion. There were no musculoskeletal deformities. Other tests mentioned in the text were negative. These findings and the patient's history suggested compression occurring primarily in the costoclavicular space involving the lower cords of the brachial plexus and the subclavian vein. The patient was given the protocol of treatment as described. After 1 0 therapy sessions, during which time the patient continued to work, she reported significant improvement in her overall symptomatology. The patient noted only occasional episodes of minimal paraesthesia. The sensation of pressure in the forearm was greatly

CONCLUSION Our preliminary results have convinced us that this particular approach to the treatment of the TOS is an effective method of managing this musculoskeletal condition (Table 1). Fifteen of the 20 patients reported a significant decrease in the number of episodes, the severity, and the extent (area involved) of the paraesthesia, numbness, and/or pain. A follow-up study was done of these 15 patients. The time that these patients were off the treatment program averaged 9% months, ranging from 1 month to 2 years. Eleven of these 15 patients reported no recurrence or regression in their condition since recieving their initial therapy treatments. The remaining four patients of this group reported slight regression; however, further therapy was not required.

TABLE 1 Physical Therapy Management of the Thoracic Outlet Syndrome: Results

a

Patient

Sex

No. of treatments

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

F F M F F F M M M M F M F M M F F F M F

8 7 7 4 6 8 6 14 8 6 6 7 3 12 9 7 7 1 9 10

Considerable im- Moderate improveprovement" mentb

Temporary improvementc

NO improvement

X X X Xd Xd Xd X Xd

X X X X X

Paraesthesia, numbness, and/or pain: very few episodes, less severe, and less area involved. Paraesthesia, numbness, and/or pain: occasional episodes and less severe. Some relief of symptoms of short duration following each treatment session. No significant or lasting results. Completely asymptomatic. Surgery: 1st rib resection.

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JOSPT Fall 1979

THORACIC OUTLET SYNDROME

The author thanks Dr. Gustav E. Kappler Ill for stimulating the author's interest in finding and developing a more effective approach to the conservative management of the TOS.

REFERENCES: 1. Lord JW Rosati LM: Thoracic outlet syndromes. Clinical Symposia. Summit, New Jersey. ClBA Pharamaceutical Company, 1971, pp 1-32 2. Roos DB: Congenital anomalies associated with thoracic outlet syndrome. Am J Surg. 132:12. 1976 3. Urschel HC. Paulson DL, McNamara JJ: Thoracic outlet syndrome. Ann Thorac Surg. 6.1 , 1968 4. Cyriax J: Textbook of Orthopedic Medicine. Vol 1. Sixth Edition, London. HK Lewis and Company. 1976. pp 61 -98. 169-1 79 5. Cailliet R: Neck and Arm Pain. Philadelphia, FA Davis Company. 1964, pp 92-96 6. Stoddard A: Manual of Osteopathic Practice. New York, Harper and Row, 1969, pp 21 4-21 6

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7. Mennell JMcM: Musculoskeletal Pain. Boston. Little. Brown, and Company, 1976, pp 209-21 1 8. Mennell JMcM: Joint Pain. Boston, Little, Brown, and Company, 1964, PP 1-31, 87-90 9. Beetham WP Jr. Polley HF. Slocumb CH. Weaver WF: Physical Examination of the Joints. Philadelphia, WB Saunders Company. 1965. pp 1-1 21 10. Hoppenfeld, S: Physical Examination of the Spine and Extremities. New York. Appleton-Century-Crofts. 1976. pp 1-1 32 11. Stoddard. A: Manual of Osteopathic Technique. London, Hutchinson Medical Publications. 1972, pp 99. 120-1 23. 171. 172. 174, 175 12. Kaltenborn, FM: Manual Therapy for the Extremity Joints. Oslo; Olaf Norlis Bokhandel, 1974, pp 86, 87 13. Maitland GD: Peripheral Manipulation. London. Butterworth and Company, 1974, pp 148, 149 14. Dale AW, Lewis MR: Management of Thoracic Outlet Syndrome. Ann Surg, 181:5, 1975, pp 575-585 15. Cailliet R: Shoulder Pain. Philadelphia, FA Davis Company. 1966, pp 101-106