Thoracic Outlet Syndrome: An Often Overlooked Cause of

Upper Arm Pain Angela Cavanna, DO, FAOASM College Physician Bard College

Assistant Clinical Professor of Medicine Touro College of Osteopathic Medicine

Middletown, NY angela.cavanna@touro.edu

mailto:Angela.cavanna@touro.edu

Disclosures - NONE

Thoracic Outlet Syndrome: Definition

Thoracic outlet syndrome (TOS) refers to a constellation of signs & symptoms that arise from compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle, within the confined space of the thoracic outlet.

• cervical rib syndrome • scalene anticus syndrome • costoclavicular syndrome • hyperabduction syndrome • Paget-Schroetter syndrome • effort vein thrombosis • shoulder-hand syndrome

Types of TOS

1. Neurogenic (nTOS) from brachial plexus compression (95%) • “true” vs “disputed”

2. Venous (vTOS) from subclavian vein compression (3%)

3. Arterial (aTOS) from subclavian artery compression (1%)

http://aclandanatomy.com/

Understanding the anatomy &

biomechanics of the thoracic outlet

is key to understanding the

symptoms!!

https://www.anatomy.tv/html5ui/#/product/har_shoulder_2014/type/Movies/id/9083619

https://www.anatomy.tv/html5ui/#/product/ifa3/type/Movies/id/9646987

Why do we care? Recent: • Tyson Ross, Matt Harvey, Mike

Foltynewicz, Luke Hochevar, Phil Hughes, Josh Beckett, Jaime Garcia, Kyle Zimmer, Chris Carpenter, Matt Harrison, Chris Young, Clayton Richard, Noah Lowry and Shaun Marcum

• Older cases: • 1980 J.R. Richard

https://www.foxsports.com/mlb/story/mlb-is-thoracic-outlet-syndrome-becoming-a-major-worry-101416 Jun 30, 2017

https://www.foxsports.com/mlb/story/mlb-is-thoracic-outlet-syndrome-becoming-a-major-worry-101416

TOS: Baseball Late cocking & acceleration phases: • Shoulder:

• Abducted • Horizontal extension &

external rotation

• Scapula & clavicle maximally retracted

• Space between first rib and clavicle decreased ~50%

https://www.anatomy.tv/html5ui/#/product/ifa3/type/Views/id/44438/layer/13/angle/35/structureID/-1

Taryn Miller

Steven Stamkos

Chris Kreider

Andrei Vasilevski

Anthony Kim

And not just baseball!!

Markelle Fultz

Thoracic Outlet Syndrome

• Estimated incidence is 10 in 100,000, but cadaveric studies have suggested that up to 90% of the population may have what is considered abnormal anatomy of the thoracic outlet¹

• 4:1 female to male ratio¹ • 2017 Otoshi et al concluded that about one-third (32.8%) of 1288 high

school baseball players screened had symptomatic thoracic outlet syndrome (TOS)²

1. Buller et al, Thoracic Outlet Syndrome: Current concepts, imaging Features, and Therapeutic Strategies, AMJOrthopedica, August 2015, 376-382

2. Otoshi et al. The Prevalence and Characteristics of Thoracic Outlet Syndrome in High School Baseball Players. Health, 2017, 9, 1223-1234.

Thoracic Outlet Syndrome Etiology¹

• Congenital • Cervical ribs • Anomalous 1st rib

• Repetitive Activities • Overhead • Closed chest : keyboard

• Acute trauma • Most common! • Hyperextension of the neck

1. Sanders & Annest. Thoracic outlet and pectoralis minor syndromes, Seminars in Vascular Surgery 27(2014)86-117

https://natashahayden.ca/wp-content/uploads/2014/05/x-ray-of-bad-posture.jpg

Thoracic Outlet Syndrome: Symptoms Neurogenic Forms of TOS:

• Pain • Dysesthesia • Numbness • Weakness

• Symptoms are reproducibly aggravated by any activity that requires elevation or sustained use of the arms or hands

• Prolonged, severe compressions of brachial plexus can lead to muscle weakness and atrophy, but this finding is extremely rare.

• Slowly progressive unilateral atrophic weakness of the intrinsic hand muscles that is more evident on the thenar aspect of the hand rather than the hypothenar aspect

• Sensory abnormalities in the T1 distribution are common

May not be localized in specific peripheral nerve distribution

Thoracic Outlet Syndrome: Symptoms

• Venous Forms of TOS: • More common in overhead activities

• “effort thrombosis” • Swelling, pain, or cyanosis of extremity • Paraesthesia in fingers • Collateral venous changes over shoulder, neck or chest

wall

• Arterial Forms of TOS: • Young patient without risk factors for vascular disease • Ischemic symptoms of hand • Pain, pallor, paraesthesia, cold, decreased pulses • Bruit or thrill in supraclavicular region

Thoracic Outlet Syndrome: Physical Exam

• Most forms of TOS are diagnosed based on history and physical exam findings

• Palpate for areas of tenderness: • Anterior scalene; biceps & rotator cuff tendons; trapezius & rhomboids;

pectoralis minor; axilla

• Tinel’s sign may be present: • Anterior scalene; carpal tunnel, medial epicondyle, pronator tunnel, radial tunnel

• Provocative maneuvers

Adson’s Test • Anterior Scalene • Positive test = decrease in the

STRENGTH of the radial pulse

https://learnmuscles.com/blog/2017/08/14/special-orthopedic-assessment-tests-thoracic-outlet-syndrome-adsons-edens-wrights/

https://www.semanticscholar.org/paper/Thoracic-outlet-syndrome.-Ozoa-Alves/50cb335961304333f3147b43ffe0438d6da9fcad

Wright’s Test • Hyperabduction test • Pectoralis minor syndrome • Positive test= decrease in the

STRENGTH of the radial pulse

https://www.semanticscholar.org/paper/Thoracic-outlet-syndrome.-Ozoa-Alves/50cb335961304333f3147b43ffe0438d6da9fcad/figure/2

https://www.youtube.com/watch?v=17Aia85ztEE

Eden’s Test • Military brace test • Costoclavicular syndrome • Positive test = decrease in the

STRENGTH of the radial pulse

https://learnmuscles.com/blog/2017/08/14/special-orthopedic-assessment-tests-thoracic-outlet-syndrome-adsons-edens-wrights/

https://www.semanticscholar.org/paper/Thoracic-outlet-syndrome.-Ozoa-Alves/50cb335961304333f3147b43ffe0438d6da9fcad

Roos or “EAST” (Elevated Arm Stress Test)

• Most accurate clinical test! • Patient seated, shoulders 90°

abducted, elbow flexed 90°, examiner instructs patient to open & close fists ~2x/sec for 3 minutes

• Positive test = reproduction of the patient’s symptoms

https://medisavvy.com/shoulder-roos-test/

Upper Limb Tension Test

• Position1: • Arms at 90 degrees, elbows

extended • Position2:

• Wrists dorsi-flexed • Position3:

• Head tilt • Positive test = reproduction of

symptoms • False negatives are rare

Sanders & Annest. Thoracic outlet and pectoralis minor syndromes, Seminars in

Vascular Surgery 27(2014)86-117

TOS: Diagnosis • Mostly clinical • Rule out other etiologies of

pain/symptoms • X-ray of cervical spine and chest to look

for cervical/anomalous rib • Ultrasound of supraclavicular region • MRA or CTA if vascular symptoms

present • EMG

• Helpful only if “true” neurogenic TOS • Often normal

• Muscle blocks • Pectoralis minor or anterior scalene • Only done over tender muscles

TOS: Treatment • Anticoagulation for thrombosis • Conservative Treatment:

• Preferred modalities: • Osteopathic manipulation (OMM) • Neck stretching • Pectoralis minor stretching • Posture correction • Nerve glides • Abdominal breathing • Dry needling

• Ineffective modalities: • Strengthening exercises • Resistance exercises • Therabands

Sanders & Annest. Thoracic outlet and pectoralis minor syndromes,

Seminars in Vascular Surgery 27(2014)86-117

Thoracic Outlet Syndrome(TOS): Treatment • Operative:

• Surgery indicated when conservative treatment fails or vascular symptoms progress

• Several techniques/approaches are available and are dependent upon the experience of the surgeon and the clinical presentation of the patient

• e.g. ATOS may require removal of clot if thrombosis present and repair of an aneurysm if the syndrome has been relatively asymptomatic and long term

• 2017 Thompson et al reported a reported that 77% of pitchers returned to play with little to no changes in their performance metrics after surgical decompression for NTOS

Thompson et al. Performance Metrics in Professional Baseball Pitchers before and after Surgical Treatment for Neurogenic Thoracic Outlet Syndrome, Ann Vasc Surg 2017:39:216-227. Photos:Sanders & Annest. Thoracic outlet and pectoralis minor syndromes, Seminars in Vascular Surgery 27(2014)86-117

Take Home Points!

• Review the anatomy of the thoracic outlet.

• Most common form of TOS is caused by trauma!

• Think of TOS in any athlete complaining of upper extremity pain.

• Consider adding provocative maneuvers to your exam.

https://www.havredailynews.com/photos/big/520321/12

References • https://www-uptodate-com.lb-proxy16.touro.edu/contents/overview-of-thoracic-outlet-

syndromes?search=thoracic%20outlet%20syndrome&source=search_result&selectedTitle=1~49&usage_type=default&display_rank=1

• http://aclandanatomy.com/ • https://www.anatomy.tv/html5ui/#/product/har_shoulder_2014/type/Movies/id/9083619 • Matthew A. Posner, Christopher J. Roach and Brett D. Owens. Vascular Problems and

Thoracic Outlet Syndrome. DeLee & Drez's Orthopaedic Sports Medicine, 59, 666-677.e2 • Sanders & Annest. Thoracic outlet and pectoralis minor syndromes, Seminars in Vascular

Surgery 27(2014)86-117 • Buller et al, Thoracic Outlet Syndrome: Current concepts, imaging Features, and Therapeutic

Strategies, AMJOrthopedica, August 2015, 376-382 • Otoshi et al. The Prevalence and Characteristics of Thoracic Outlet Syndrome in High School

Baseball Players. Health, 2017, 9, 1223-1234. • Thompson et al. Performance Metrics in Professional Baseball Pitchers before and after

Surgical Treatment for Neurogenic Thoracic Outlet Syndrome, Ann Vasc Surg 2017:39:216-227.

https://www-uptodate-com.lb-proxy16.touro.edu/contents/overview-of-thoracic-outlet-syndromes?search=thoracic%20outlet%20syndrome&source=search_result&selectedTitle=1%7E49&usage_type=default&display_rank=1https://www-uptodate-com.lb-proxy16.touro.edu/contents/overview-of-thoracic-outlet-syndromes?search=thoracic%20outlet%20syndrome&source=search_result&selectedTitle=1%7E49&usage_type=default&display_rank=1https://www-uptodate-com.lb-proxy16.touro.edu/contents/overview-of-thoracic-outlet-syndromes?search=thoracic%20outlet%20syndrome&source=search_result&selectedTitle=1%7E49&usage_type=default&display_rank=1http://aclandanatomy.com/https://www.anatomy.tv/html5ui/

Thoracic Outlet Syndrome:�An Often Overlooked Cause of Upper Arm PainDisclosures - NONEThoracic Outlet Syndrome: DefinitionTypes of TOSSlide Number 5Slide Number 6Slide Number 8Why do we care?TOS: BaseballSlide Number 11Thoracic Outlet Syndrome Thoracic Outlet Syndrome Etiology¹Thoracic Outlet Syndrome: SymptomsThoracic Outlet Syndrome: SymptomsThoracic Outlet Syndrome: Physical ExamAdson’s Test Wright’s Test Eden’s Test Roos or “EAST”�(Elevated Arm Stress Test) Upper Limb Tension TestTOS: DiagnosisTOS: TreatmentThoracic Outlet Syndrome(TOS): TreatmentTake Home Points!References