142. Intro to Thoracic Outlet Syndrome

Join us in this episode of PT Snacks podcast as we dive into Thoracic Outlet Syndrome (TOS). This episode explores the causes, types, and diagnostic criteria of TOS. It includes an overview of provocation tests, symptom patterns, and potential treatment strategies, emphasizing the importance of ruling out other diagnoses. Additional resources and further reading options are provided for those wanting to expand their knowledge.

00:00 Introduction to Thoracic Outlet Syndrome

00:46 Understanding Thoracic Outlet Syndrome

01:32 Types of Thoracic Outlet Syndrome

02:35 Diagnosing Thoracic Outlet Syndrome

03:51 Clinical Presentation and Symptoms

05:06 Differential Diagnosis

06:22 Physical Therapy Management

08:04 When to Refer for Surgery

08:53 Key Takeaways and Resources

Hock, G., Johnson, A., Barber, P., & Papa, C. (2022). Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome.. Journal of athletic training. https://doi.org/10.4085/1062-6050-138-22.

Jones, M., Prabhakar, A., Viswanath, O., Urits, I., Green, J., Kendrick, J., Brunk, A., Eng, M., Orhurhu, V., Cornett, E., & Kaye, A. (2019). Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain and Therapy, 8, 5 - 18. https://doi.org/10.1007/s40122-019-0124-2.

Transcript

0:27

Treating a patient with weird arm symptoms that you don't know where they're coming from. Dive in with me today as we cover thoracic outlet syndrome. Hey everyone. Welcome to PT Snacks podcast. This is Kasey your host and if you're tuning in for the very first time, what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bite-size segments of time. And before we dive into today's topic, if you have listened to at least three episodes and you've really found them to be helpful, if you wouldn't mind leaving a review on wherever you're listening to this, that would mean the world to me. That would mean the world to me.'cause those really do help to make this podcast reach more and more people. But without further ado, today we're gonna cover thoracic outlet syndrome, what exactly it is what common types we might see in PT if we do see them and some things to help us rule it in or rule it out with our exam. So when we're talking about thoracic outlet syndrome or TOS, it's a condition that's caused by compression of the neurovascular bundle, somewhere between the neck and the axilla. So usually from three potential spaces. The inters scalene triangle, the costal clavicular space, and the subcoracoid or pec minor space. These particular sites are sites of potential compression that we wanna look at to see is this causing symptoms down this patient's arm or could it be something else? So there's three main types because when we're thinking about a neurovascular bundle, we are thinking about the nerves, veins, and arteries. There is neurogenic TOS or NTOS you might have seen in research. This is when it's more so the nerve that is being compressed, and that's gonna be like 90% of cases. So this is usually what most PTs will be dealing with. Venous, TOS or VTOS is about 5% and usually presents with swelling or cyanosis. And arterial, TOS or a TOS is like less than 1%, but pretty high risk. Think cold hands, pale hands, and diminished pulses. So there's a paper from 2019 in Pain Therapy Review by Jones Etal that does a pretty good job of breaking this down and talks about how frequently this condition is missed or misdiagnosed because it is a diagnosis of exclusion. We'll talk more of that in the future, but it is good to be aware of some other potential diagnoses if you're feeling stuck with what's going on in your patient. So how do we actually know that we're dealing with TOS? So in the 2016 core TOS consists guidelines, this. Is essentially some common factors that they identified as what you would need to make a clinical diagnosis. So one is a consistent symptom pattern, and we'll talk more about that in a second. Positive symptom reproduction with a particular movement or position or posture. They said no other obvious pathology explaining it, so this is why it's a diagnosis of exclusion. And ideally, there's multiple provocation tests that recreate the symptoms. And those provocation tests include things like roos tests, the elevated arm stress test, tinnels at the thoracic outlet, atin maneuver OC clavicular and rights test. But none of these particular provocation tests are really good on their own. So you wanna do multiple because sensitivity and specificity of these. Tests are all over the place. So instead of relying on just one again, use multiple, combine that with subjective history what you're seeing in your exam, palpation, test response, et cetera. What does someone with TOS actually look like? A lot of papers that are describing this will talk about patients who have pretty poor posture. Common other common reported symptoms can be symptoms with overhead activity or prolonged positioning, especially like typing or lifting. Symptoms can be non-specific and intermittent, these symptoms can be anything from numbness, heaviness, achy. Aching tingling typically in an ulnar distribution, but it's not neatly dermato, so it can be just vague symptoms. They may have tenderness at one of these sites of entrapment, like the scaling triangle or under the PEC minor, and in vascular cases you might see swelling sinuses or cold hands. So you're looking out for the white hand sign during provocation tests. An example of this might be you. Your patient might be talking about, Hey, my hand goes numb when I'm blow drying my hair in the morning after a certain amount of time. But my MRI was clean and nothing really seems to help. So things like that need a deeper dive into looking at what exactly is going on. So when we are. Looking for a TOS, we're looking for potential signs of a nerve compression symptom. We still want to make sure that we're rolling out things like, Cervical radiculopathy or an ulnar or median nerve entrapment shoulder instability or even pancoast tumors. If you're studying for your OCS, you should definitely know that one. So when we are consistent with our examination techniques and we're looking to differentiate what tissue seems to be involved? Does it seem mechanical? Does it seem joint related, muscular related, nerve related. From there, we should be looking at their range of motion, their joint mobility diving into things like upper limb tension tests, myotomes, dermatomes reflexes, which all can be normal in neurogenic TOS. Are they tender to palpation? Our provocation tests, like we have Rus, addons, tens looking at Costa Clavicular like in an exaggerated military posture. Things like that. Ideally ruling out other causes before we get to this. And the reason why is there's not really a gold standard for determining if someone has thoracic outlet syndrome, at least not at this point. So let's say we've ruled everything out, we're pretty sure it's TOS. If the patient has neurogenic TOS, which is 90% chance that it is, this is where physical therapy can make a big difference. This is where we're looking to calm things down. If they're using like their accessory muscles for breathing instead of diaphragmatic breathing, we can teach them that. Maybe try and modify what positions are provocative to them so that we can help them live their life. And then even from a. Mobility perspective. If there's some sort of compression we are identifying we're trying to offload the compression, right? So things like a first rib mobilization if applicable. Any soft tissue work to scalings, elevator, upper trap, pec, minor thoracic extension and rotation, mobility, pec minor and anterior chest while stretching. Things like that as applicable and reasonable to your patient. Are things that you can consider and then building strength and control as well. Most research sites support for training the deep neck flexors, serratus, anterior low trap, mid trap focusing on scapular upward rotation and a posterior tilt. Help depending on what the patient is having issues with overhead motion, endurance, things like that to kinda help them to have less posi to help them to have less symptoms in these positions. And then just basically helping to work them and on a progressive program towards getting back to their normal routine with however long they need to do the activity that is bothersome. Techniques that they can do to help reduce their symptoms if they do feel it, things like that. Now if your patient has cold pulseless or discolored hands, significant swelling progressively. Is progressively worsening with neurological symptoms and there's no improvement after six to eight weeks of consistent care. These are probably patients that need to be referred to vascular surgery or neurology. Surgery is pretty rare for neurogenic TOS, but often needed for venous or arterial TOS or if someone's failed conservative management. Now, if someone is having. Emergent symptoms before that six to eight weeks, definitely send them on or it's good to go ahead and make sure they have a consultation with a surgeon who specializes in this area so that if they need a quick solution, it's already there set in play for them. Big takeaways from today TS is. Something to have on your radar, and while it can be overlooked'cause of the upper extremity symptoms, just keep in mind that it is a diagnosis of exclusion. You do need to do your due diligence of ruling out other things. Also make sure that your findings that you're using to support your diagnosis of TS are a cluster of symptoms, their history, their posture, provocation tests. All these things are pointing towards TOS, and you've already rolled out other potential diagnoses on your list. And then keep in mind, PT can be very effective for neurogenic TUS. Work your way towards calming symptoms, down, helping to offload what area that you've identified is compressing the neurovascular bundle, and then help to prevent it from being compressed with your treatment plan. So I know this is very vague and really this. Topic could be a much deeper topic. But the purpose of this episode is really just to put TOS on your radar. If you haven't thought about it in a while, here's a brief review of things that you can utilize and also maybe a jumping a launch pad for you to further research. So I am gonna add a few articles in the show notes. There's. Lots and lots out there. But if you have someone who you are suspicious may have this condition hopefully those are helpful for pointing you in the right direction or pointing you towards a different direction. So feel free to reach out at PTs Snacks podcast@gmail.com with any questions and if you do have any and. Now if you're in need of now, med Bridge Court actually has a ton of courses on TOS by Anne Perato. Loki, I am definitely mispronouncing it. So I'm sorry, Anne. But there's one called the identification, evaluation of thoracic outlet syndrome. It's about two hours treatment of thoracic outlet syndrome, where to begin? It's an hour and a half treatment of thoracic outlet syndrome, addressing shoulder and upper thoracic limitations and thoracic outlet syndrome assessing the elevation. Chain, which is about an hour and 25 minutes. Definitely if you wanna take a deeper dive and you already have a Med Bridge account, there's some there for you too. If you are looking to get some more CCUs or you're interested in getting a Med Bridge account, they're actually offering listeners of this show over a hundred dollars off their subscription. So definitely use the promo code and the. Use the promo code in the description down below, and that will get you that discount, and if you're a student, you get even more off, so there's a special discount promo code for you. Other than that, I hope you guys have a great rest of your day, and until next time.