Practice What You Preach: A Case Study on My Self-Management of Thoracic Outlet Syndrome

I have a confession to make: I have been a hypocrite. However, if you give me the time to elaborate, maybe you will not hold my hypocrisy against me. I have been taught to educate patients how to take ownership of whatever problem(s) led them to seek physical therapy; and I have put those skills into practice in my limited experience of treating patients to this point. Rather than following my own advice, I have ignored the symptoms of thoracic outlet syndrome (TOS), which have gradually increased in severity over time. I decided that it was time to finally practice what I preach and use my knowledge and skills to treat myself. Not only is it necessary that we, as physical therapists and physical therapy students, maintain our health and well-being, but we can also benefit from the actual exercise of evaluating and treating ourselves when injuries or other problems arise. So I’m going to approach my pathology as if I was my own patient walking through my own doors.


Presentation

So let’s begin with an examination and evaluation. For the purpose of this blog, I am going to include only pertinent findings, even though I would go through a full and thorough examination. My symptoms began to appear about 12 months ago - yes, I know, I should have addressed this far sooner - whenever I would go for a run. After 4 to 5 miles, I would begin to feel paresthesia in the fourth and fifth fingers of my right hand and up into my medial forearm. The symptoms disappeared within seconds to minutes of ending my run. As time has progressed, I have noticed that the symptoms have gradually begun to appear earlier in my runs, to the point I now feel them after about two miles, and I even occasionally feel them while at rest.

Other observations included:

  • My posture: I present with forward head, bilateral rounded shoulders, and both scapulae tipping slightly anteriorly.
  • My running posture: My scalene and sternocleidomastoid muscles are excessively prominent. My right shoulder is held slightly higher than the left shoulder.
  • Palpation: Applying pressure to my upper trapezius muscles indicates they are hypertonic bilaterally.
  • Muscle flexibility: I found tightness in bilateral scalene muscles, pectoralis major and minor, and upper trapezius.
  • Joint mobility: My first rib is elevated and extremely hypomobile.

From the information I gathered up to this point, it is apparent I am likely suffering from some sort of neural compression. Looking solely at the location of the symptoms, it could potentially be due to compression of the ulnar nerve or the C8 nerve root. When considering the additional evaluation information, and the circumstances under which the symptoms occur, compression of the C8 nerve root at the lower trunk of the brachial plexus due to TOS is the most likely scenario. To help confirm my diagnosis, and to potentially narrow down the area of compression, I decided to perform some special tests. Research by Gillard et al. stated two positive provocative tests for TOS taken together have a sensitivity of 90%, and a cluster of five positive tests has a specificity of 84%. Based on this information, I should use multiple tests to help rule in my diagnosis. There are several special tests a physical therapist can use to test for TOS, each of which can help contribute to an accurate diagnosis and can potentially help determine the sight of compression (see table at bottom of page).

Special test examination revealed: the costoclavicular maneuver, Wright’s test, Adson’s test, Roos stress test, and upper limb tension test were all positive on my right side and negative on my left side. All of the listed tests elicited paresthesia along the C8 distribution, without any pain or diminishment of my radial pulse. I had a cluster of five positive tests, so, when put together with my other findings, I can say with confidence that I likely have thoracic outlet syndrome on my right side.

 

Treatment

I now need to implement some treatment techniques on myself. Based on my presentation, I have neurogenic TOS, with the lower trunk of the brachial plexus being compressed. The pectoralis minor and anterior scalene are the most likely causes of compression based on my physical findings and positive tests. The brachial plexus can be compressed when passing between the anterior and middle scalani, when it passes between the first rib and clavicle, or when it passes underneath the pectoralis minor tendon.

The evidence is somewhat lacking on how to best conservatively manage thoracic outlet syndrome. TOS is actually a cluster of symptoms resulting from the compression of the nerves in a variety of locations and for a variety of reasons (tight muscles, poor posture, joint hypomobility, etc.). Because of this, it is a difficult pathology to research and to establish standard methods of treatment for it. However, there is evidence to demonstrate the efficacy of conservative management of neurogenic TOS. I can use my examination findings to determine what areas to address. In my case, I have been stretching my scalene muscles, pectoralis major and minor, and upper trapezius. I have begun mobilizing my first rib and clavicle, and gliding and tensioning my cervical nerve roots. I am concentrating on improving my daily posture and my running posture, while also avoiding provocative activities. As I continue with my self-treatment of the condition, I am gradually reintroducing activities that cause symptoms with the goal of returning to symptom-free, full activity. To finalize my thoughts, there can be more than one method to address these deficiencies. The important thing is to recognize what needs to be treated, then to implement a plan for how to treat it.


An important note to keep in mind when dealing with TOS: while neurogenic TOS is the most common form, and can typically be conservatively managed, there are also arterial and venous types of TOS that can potentially become medical emergencies. Patients who display symptoms of vascular occlusion of the subclavian artery or vein should be referred to a physician for further evaluation.

I encourage everyone that reads this to learn from my mistakes and practice what you preach. If I followed the advice I would normally give a patient when I began feeling these symptoms nearly a year ago, I would not be writing about this right now. However, injuries do happen. So, I encourage you to find the silver lining in your injury and take the opportunity to go through the practice of self-examination and treatment. Obviously, some injuries require further medical attention or more thorough evaluation than you can provide for yourself - I am not advocating attempting to treat yourself in such instances - but, even in those cases, take the opportunity to read up on the available research about that injury.

As always, we would love to hear any feedback from our readers. Let us know if you find this exercise to be useful, if you have done any sort of treatment on yourself, and how it went. For more information about TOS, click on the any of references listed below.


Test Sensitivity Specificity Description
Costoclavicular Maneuver Not Specified 53-100% A positive costoclavicular maneuver indicates compression in the costoclavicular space. A positive test should be reproduction of symptoms rather than a change in the radial pulse. The test is performed by having the patient retract and depress the scapulae and protrude the chest for 60 seconds. The clinician should assess the radial pulse, but the patient should also be asked about any feelings of paresthesia in the arms.
Wright's Test 70-90% 29-53% A positive Wright’s test indicates compression of the brachial plexus in the thoraco-coraco-pectoral gate. It is performed by having the patient abduct the shoulders while his or her radial pulse is palpated. It is positive if the radial pulse becomes weaker or if the patient feels paresthesia. Wright’s test is low in specificity because 60-69% of patients without TOS experience a diminished radial pulse in this position. Use of Wright’s test can help to identify the axillary interval, which is the space posterior to the pectoralis minor, as the area of compression.
Adson's Test 79% 74-100% Adson’s test can be performed by having the patient hold his or her breath after inhaling deeply and extend and rotate the neck toward the tested side. The patient’s radial pulse is assessed throughout, and the test is considered positive if the radial pulse becomes diminished or if the patient feels paresthesia. Despite the fact that the motion performed in this test increases the scalene angle, it has a specificity of 89% when assessing for vascular occlusion or paresthesia and 100% when evaluating for pain.
Supraclavicular Pressure Test Not Specified 85-98% A positive Supraclavicular pressure test and a positive Adson’s test indicate brachial plexus compression in the scalene triangles. The supraclavicular pressure test is performed with patient seated while the clinician places his or her fingers on the patient’s upper trapezius and thumb on the patient’s anterior scalene. The clinician then squeezes his fingers and thumb together in order to induce pain or paresthesia. Morley’s sign is when there is tenderness of the supraclavicular fossa. It may indicate TOS if it is only positive on one side and if it elicits pain distally.
Roos Stress Test/Elevated Arm Stress Test 52-84% 30-100% The patient abducts shoulders to 90 degrees, externally rotates the shoulders, and flexes elbows to 90 degrees. Then, the patient opens and closes his or her hands repeatedly. The test is positive if symptoms are reproduced or if the patient cannot hold his or her arms up for three minutes.
Cyriax Release Test Not Specified 77-97% While Roos test loads the brachial plexus throughout the thoracic outlet, the Cyriax release test does the opposite by unloading the brachial plexus in the thoracic outlet. To perform the Cyriax release test, the clinician holds underneath the patient’s forearms from behind and pulls the patient’s trunk posteriorly while the scapulae are passively elevated. The patient’s elbows are held at 80 degrees of flexion with the forearms and wrists in their neutral positions. The test is positive if paresthesia or numbness is felt or if symptoms are recreated. The feeling of numbness during the unloading of the brachial plexus in the thoracic outlet is called the release phenomenon.
Upper Limb Tension Test 90% 38% The upper limb tension test produces irritation of entire brachial plexus. In the supine position with the neck laterally flexed to the contralateral side, the patient’s scapula is passively depressed while the shoulder is abducted to 110 degrees and slightly extended. The elbow begins in 90 degrees of flexion. The forearm is fully supinated and the wrist and fingers are extended. The test is completed by extending the patient’s elbow. The test is positive if symptoms are replicated any time during the test or if elbow extension is limited.

References

1.      Balakatounis KC, Angoules AG, Panagiotopoulou KA. Conservative treatment of thoracic outlet syndrome (TOS): Creating an evidence-based strategy through critical research appraisal. Current Orthopaedics. 2007;21(6):471-476.

2.    Nichols AW. Diagnosis and management of thoracic outlet syndrome. Curr Sports Med Rep. 2009;8(5):240-9.

3.     Fugate MW, Rotellini-coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med. 2009;11(2):176-83.

4.    Gillard J, Pérez-cousin M, Hachulla E, et al. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint Bone Spine. 2001;68(5):416-24.

5.    Hooper TL, Denton J, Mcgalliard MK, Brismée JM, Sizer PS. Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip Ther. 2010;18(2):74-83.

6.    Hooper TL, Denton J, Mcgalliard MK, Brismée JM, Sizer PS. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. J Man Manip Ther. 2010;18(3):132-8.

7.     Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y, Descatha A. Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. J Occup Rehabil. 2011;21(3):366-73.

8.    Nee RJ, Vicenzino B, Jull GA, Cleland JA, Coppieters MW. A novel protocol to develop a prediction model that identifies patients with nerve-related neck and arm pain who benefit from the early introduction of neural tissue management. Contemp Clin Trials. 2011;32(5):760-70.

9.    Nitz AJ, Nitz JA. Vascular thoracic outlet in a competitive swimmer: a case report. Int J Sports Phys Ther. 2013;8(1):74-9.

10.    Povlsen B, Belzberg A, Hansson T, Dorsi M. Treatment for thoracic outlet syndrome. Cochrane Database of Systematic Reviews 2010, Issue 1

11.     Twaij H, Rolls A, Sinisi M, Weiler R. Thoracic outlet syndromes in sport: a practical review in the face of limited evidence--unusual pain presentation in an athlete. Br J Sports Med. 2013;47(17):1080-4.

12.     Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways. Man Ther. 2009;14(6):586-95.