Research-Based Assessment of Thoracic Outlet Syndrome

A thorough evaluation is extremely important in determining the type of TOS and it is only after this that a proper treatment approach can be formulated, based on the assessment. During the initial evaluation of a patient with TOS, several key elements must be taken into consideration. A thorough history should include questions about any recent trauma to the neck, shoulder or arm; recent activities that required prolonged use of the upper extremities or the neck in awkward positions; and any repetitive activities that put stress on the neck, shoulder or arm. Be aware of differential diagnosis findings such as pain, weakness, numbness, coolness, etc. On physical examination, note the patient’s posture, muscle asymmetries, and any deformities. Also compare extremities regarding color, muscle atrophy, muscle tone and edema.(2) On palpation, check for tenderness, masses, muscle tension (especially in scaleni and pectorals), and reproduction of symptoms with palpation in the interscalene triangle and supraclavicular space.  Range of motion and strength testing should be performed and compared bilaterally, as well as the special tests indicated above.  The elevated arm stress test is another special test for TOS. It is performed by having the patient sit or stand with both shoulders in ninety degrees of abduction and external rotation, and the elbows in ninety degrees of flexion. The patient is then asked to open and close both hands for 3 minutes. The patient with TOS may have the inability to maintain this test position because of pain or sensory/motor disturbances. (10) There is considerable controversy about the reliability and validity of these special tests and therefore information gained from these tests should be used in conjunction with a complete evaluation.(2)
In some cases, imaging studies may prove beneficial.  X-rays of the area can reveal anatomic anomalies such as cervical ribs, healed fractures, arthritic changes, etc.  Magnetic resonance imaging (MRI) or computed tomography (CT Scan) may reveal important structural relationships between bony and soft tissues.(2) To evaluate venous or arterial compromise, most physicians consider conventional venography or arteriography the most reliable tests.(11) In neurogenic TOS, nerve conduction studies and electromyography (EMG) may be valuable to confirm TOS and rule out cervical radiculopathy and peripheral neuropathies.

Research-Based Treatment of Thoracic Outlet Syndrome

Treatment of the thoracic outlet patient can be a complex and challenging problem. Treatment is dependent on the type of TOS. Arterial TOS is often treated more aggressively due to the threatening complications indicated above. Consultation with a vascular surgeon is the initial step in management.(2) For the most part, the literature supports conservative care as the preferred approach for TOS patients and, therefore, therapy plays an important role in caring for these patients. Often these patients are suffering from additional complaints, including active myofascial trigger points in the neck and shoulders, glenohumeral joint pathologies, cervical pathologies, or peripheral neuropathies. Treatment should initially address reducing symptoms to provide relief and then progress to the neurovascular component.

Research-Base Massage Therapy for Thoracic Outlet Syndrome

Treatment can include soft-tissue massage techniques like myofascial release, neuromuscular therapy and trigger point massage. Myofascial release takes into consideration the fascial component of muscle and tendon to achieve a lasting effect. The pain of TOS is intimately connected with short, contracted muscles that develop trigger points. These areas of tight muscle fibers can have local ischemia that creates a pain-spasm-pain cycle. Neuromuscular therapy addresses trigger points in key muscles, especially the scaleni, upper trapezius, levator scapulae, pectoralis minor and the Sternocleidomastoid (SCM),.  Other muscles that may be targeted are the sub-occipitals, pectoralis major, and cervical paraspinals.(2)
Watch the complementary video on page 1 to see techniques that Dr. Mark uses on his patients with TOS.

In one study, TOS was treated successfully with myofascial release massage and stretching. The myofascial release technique involved local release of myofascial structures, including the scaleni, levator scapulae, upper trapezius, SCM and pectoralis minor. (5)

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