Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management

Abstract

Background: Proper management of thoracic outlet syndrome (TOS) requires an understanding of the underlying causes of the disorder. A comprehensive examination process, as described in Part 1 of this review, can reveal the bony and soft tissue abnormalities and mechanical dysfunctions contributing to an individual's TOS symptoms.

Objective: Part 2 of this review focuses on management of TOS.

Conclusion: The clinician uses clinical examination results to design a rehabilitation program that focuses on correcting specific problems that were previously identified. Disputed neurogenic TOS is best managed with a trial of conservative therapy before surgical treatment options are considered. Cases that are resistant to conservative treatment may require surgical intervention. True neurogenic TOS may require surgical intervention to relieve compression of the neural structures in the thoracic outlet. Surgical management is required for cases of vascular TOS because of the potentially serious complications that may arise from venous or arterial compromise. Post-operative rehabilitation is recommended after surgical decompression to address factors that could lead to a reoccurrence of the patient's symptoms.

Keywords: Conservative management; Review; Surgical management; Thoracic outlet syndrome.

Figure 1

Cyriax release maneuver. The patient is positioned in a chair, elbows flexed to 90° and placed on toweling at a height that sufficiently produces a passive shoulder girdle elevation. The patient sits upright with spine supported and the head in neutral. The forearms and wrists are positioned in neutral. The position is held until peripheral symptoms are produced. The patient is encouraged to allow symptoms to occur as long as can be tolerated up to 30 minutes, observing for a symptom decrescendo as time passes.

Figure 2

First rib mobilization. (A) Costovertebral (CVJ) mobilization: the patient is positioned with the head mildly elevated and the cervical spine rotated away from the treatment side. The clinician uses the (R) radial hand at the second MCP to direct the mobilization force to the cranial surface of the first rib in a caudal and contralateral direction (towards the opposite hip). (B) Costotransversal (CTJ) mobilization: the patient is positioned with the head mildly elevated and the cervical spine rotated towards the treatment side. The clinician uses the (R) radial hand at the second MCP to direct the mobilization force in a ventral and ipsilateral direction. The (L) hand is used to stabilize the (R) shoulder. Oscillatory grade III and IV mobilizations or a grade V high velocity thrust maneuver can be performed in both cases.

Figure 3

First rib self-mobilization. The patient is positioned in sitting with spine supported. The cervical spine is retracted, laterally flexed away and rotated towards the treatment side. A thin sheet strap is positioned to contact the first rib on the cranial surface 1 inch lateral to the transverse process of T1. The patient uses her own hands to pull on the sheet loop and produce a mobilization force directed caudal and contralateral (towards the opposite hip). The pictured head rotation emphasizes scalene stretch. Rotating head to opposite side emphasizes rib mobilization.

Figure 4

Glenohumeral mobilizations in end-range elevation with the elbow supported in extension. (A) Posterior glide: the patient is supine with a sandbag posterior to the scapula on the treatment side. The mobilization hand contacts the proximal humerus while avoiding contact with the coracoid process. The force is directed along a helper’s line connecting the anterior tip of the coracoid process and the posterior angle of the acromion. (B) Anterior glide: the patient is prone with a sandbag under the coracoid on the treatment side. The mobilization hand contacts the proximal humerus while avoiding contact with the acromion process. The force is directed along a helper’s line connecting the posterior angle of the acromion with the anterior tip of the coracoid process. (C) Inferior glide: the patient is prone. The stabilization hand contacts the humerus distal to the lateral acromion process. The mobilization hand contacts the axillary border of the scapula and mobilizes the scapula around the rib cage in a cranial–medial direction.

Figure 5

Manual scalene stretch. The patient is positioned supine with the chin retracted and the cervical spine laterally flexed away and rotated towards the treatment side. The clinician uses the (R) radial hand at the second MCP to direct the mobilization force in a caudal and contralateral direction (towards the opposite hip). The (L) hand is used to maintain a chin tuck.

Figure 6

Proximal neural mobilization. The patient is positioned (A) with the head mildly elevated and the cervical spine laterally flexed towards the treatment side. The patient’s arm is positioned at the side, shoulder girdle passively elevated and the elbow flexed with the forearm across the lap. The first rib is then manually depressed in a direction towards the opposite hip. (B) While maintaining the first rib depression, the cervical spine is gently and submaximally moved into lateral flexion away from the treatment side in a rhythmic fashion.