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Thoracic Outlet Syndrome: Orthopedic Tests

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WSCC Clinics Protocol Adopted: 7/08 Thoracic Outlet Syndrome: Orthopedic Tests Adson’s Test Halstead Maneuver Allen’s Test Hyperabduction Test (Wright’s Test) Costoclavicular Test (Eden’s Test) Roos Test Cyriax Release Test OVERVIEW dermatome and precede motor symptoms. The hand may also demonstrate loss of grip Thoracic outlet syndromes (AKA, cervical rib, strength, incoordination or clumsiness scalenus anticus, costoclavicular, (Murphy 2000). Other symptoms may include hyperabduction and pectoralis minor neck pain or headache. Symptoms are syndrome) are a group of syndromes usually unilateral. primarily associated with arm symptoms. Neurovascular entrapment is thought to be About 90-97% of patients have neurological caused by compression of the brachial symptoms. Far fewer have neurological signs plexus, subclavian artery and/or vein at some or significant vascular involvement (Vanti combination of the following sites: within the 2007). Thoracic outlet syndromes can be interscalene triangle, between the first rib and grouped as following: 1) vascular TOS, clavicle, and between the corocoid process which represents only 3-10% of cases; and the tendon of the pectoralis minor 2) true neurogenic TOS (N-TOS), which is muscle. (Liebensen 1988) an uncommon form of the condition and presents with neurological deficits A variety of contributing factors have been demonstratable by physical exam or suggested. Prolonged periods of using a electrodiagnosis; and 3) nonspecific computer keyboard and long periods of neurogenic TOS, which is the most common hyperabduction or elevation of the arm due to form and has neurological symptoms but no job, recreation or sleeping postures may lead deficits or electrodiagnostic findings—this to this condition. Fixed postures have also type of TOS is considered to be controversial been implicated such as forward head since there is no gold standard to confirm the carriage, shoulders rolled forward, “drooping” diagnosis (Vanti 2007). shoulder girdle, and large poorly supported breasts. Other factors occasionally include a VASCULAR TOS cervical rib, a space occupying lesion (e.g., a Pancoast tumor), recent trauma or the The vascular form of TOS is the most serious delayed effects of trauma (including and requires urgent referral for further whiplash). assessment and potential surgery. It is most common in young males, often who engage A diagnosis of thoracic outlet syndrome in strenuous activities (Huang 2004). This (TOS) is often made based on the clinical diagnosis is not based on loss of pulse during symptoms (after excluding other diagnoses) the classic TOS orthopedic tests, but rather and is not always confirmed by physical exam on a constellation of more prominent vascular findings. The dominant symptoms include signs and symptoms. About 1-2% of TOS shoulder and arm pain, paresthesia of the patients have significant venous compression fingers (often the 4th and 5th digit), a sense of (Vanti 2007). Signs and symptoms include heaviness or fatigue in the arm and swelling in the hand or arm, nonpitting sometimes pallor in the fingers. Sensory edema, distended superficial veins in the symptoms generally cover more than one upper extremity and chest, cyanosis, Thoracic Outlet Syndrome: Orthopedic Tests Page 1 of 26 ecchymosis sometimes accompanied by a NONSPECIFIC TOS feeling of heaviness or fatigue in the arm. Nonspecific neurogenic TOS (AKA, the These symptoms may be aggravated by TOS disputed form) makes up the bulk of tests, especially overhead tests. If these diagnosed cases. There do not appear to be symptoms are constant and do not disappear good prevalence estimates, but Vanti (2007) with rest or arm dependency, thrombus suggests it may account for up to 85% of formation may have occurred. Because of the TOS. Nonspecific TOS is most likely the form potential of a pulmonary embolism, the that chiropractic physicians see most patient should be referred urgently (Murphy commonly. It is more common among women 2000). and more prevalent in the 20- to 40-year-old About 1-5% have significant arterial age group. Pain and paresthesia dominate compression (Vanti 2007). This form is the clinical presentation. Symptoms often characterized by unilateral cold sensation, follow an ulnar distribution, as is the case with pallor of the fingertips, splinter hemorrhages, true N-TOS, but there are either no or only Raynaud’s-like phenomenon, asymmetrical mild neurological findings. Symptoms may decreased radial pulse, an asymmetry of also present on the median side of the hand blood pressure equal to or more than 20 or affect the entire hand or forearm. Because mmHg (the lower pressure in the of these variations, upper trunk and lower symptomatic arm), subclavian bruits, mild trunk forms of the syndrome have been signs of cramping or fatigue with repetitive suggested. Skeptics argue that the upper use, and sometimes symptoms that also form or mixed form is more likely a separate suggest neurogenic compression. condition and not caused by entrapment of the brachial plexus in the thoracic outlet. TRUE NEUROGENIC TOS (N-TOS) DIAGNOSIS True neurogenic TOS is also thought to be rare with an estimated prevalence of Diagnosis is based on a combination of 1/1,000,000 (Schenker 2001). Young thin clinical symptoms and exam findings, females are the most common patients (Vanti including positive thoracic outlet orthopedic 2007). There also appears to be a higher tests that attempt to occlude some portion of incidence of cervical ribs in this form of TOS. the outlet and reproduce the patient’s Neurologic signs dominate, often symptoms. accompanied by little or no pain. Sensory Ribbe and Lindgren (1989) proposed a loss is often the first presentation, with the cluster of findings that they claimed could be loss classically restricted to the ulnar aspect used to predict a diagnosis of TOS and of the hand and forearm. Symptoms are identify a patient for conservative care typically aggravated by overhead activities, targeting this condition. A follow-up study also carrying heavy objects and may be worse at used this TOS Index to make a TOS the end of the day and when sleeping. diagnosis and treat successfully with exercise Although they may come later, motor findings (Lindgren 1997). The diagnosis was made by and muscle atrophy are often the most salient fulfilling at least three of the following criteria: features. One classic finding is the “Gilliatt- 1) a history of symptom aggravation by Sumner hand” which displays a dramatic having the arm in an elevated position; 2) a degree of atrophy of the abductor pollicis history of C8-T1 paresthesia; 3) brevis, giving the thenar eminence a scooped supraclavicular tenderness over the brachial out appearance where the muscle mass plexus; and 4) patients unable to continue the would usually be. The interossei and Roos test for 3 minutes. hypothenar eminence may also suffer a milder degree of atrophy. The true validity of the TOS Index, as well as the accuracy of all of the TOS orthopedic tests, is difficult to know because of the lack of a gold standard. The tests under study are often folded into the reference standard used Thoracic Outlet Syndrome: Orthopedic Tests Page 2 of 26 for confirming the correct diagnosis, tainting 6 STEPS for Assessing Possible TOS the conclusion with incorporation bias. 1. Correlate TOS test results. When TOS is suspected, a working diagnosis 2. Check for neurological deficits suggesting is usually arrived at based on the entire true N-TOS. clinical presentation, which could include the 3. Check for significant arterial or venous TOS Index as well as the results of the other compromise suggesting vascular TOS commonly performed orthopedic tests. The (and the need for urgent referral). stronger the positive finding (e.g., repro- 4. Assess joint and soft tissue structures duction of pain symptoms vs. isolated loss of that may be contributing to TOS. pulse) and the greater the number of positive 5. Rule out other contributing or mimicking tests, the more specific they are thought to conditions. become (Nannapaneni 2003, Rayan 1998, 6. Decide whether ancillary studies are Vanti 2007). Because the diagnosis is made necessary. on such soft criteria, it is important to rule out other competing hypotheses. Additional procedures must be performed to further STEP 1. Correlate TOS test results. differentiate nonspecific TOS, true N-TOS, and vascular TOS. Evaluation of the joints The following tests are routinely and soft tissue may help focus a manual recommended (Brismee 2004, Karas 1990, therapy and conservative care approach. Mackinnon 1996, Nannapaneni 2003, Nichols Lastly, contributing factors may need to be 1996, Oates 1996, Ouriel 1998, Rayan 1998, identified and addressed. Schenker 2001, Schimp 1999, Talmage 1999). A Work-Up Strategy Recommended A dson’s test SUMMARY of Physical Exam Procedures Hyperabd uction test Co stoclavicular test Postural analysis (standing and sitting) Roos test Tinel’s test Palpation of the scalenes, pectoralis and other cervical and shoulder girdle Optional muscles Halstead (reverse Adson’s) test Neurological evaluation (e.g., DTRs, Cyriax release test muscle tests, and sensory testing) Palpate or percuss supra- and infra- clavicular space (Schenker 2001). Vascular evaluation (check upper extremity pulses, nail blanching, It appears best to interpret the TOS tests in temperature, swelling, auscultation for combination with each other (Nannapaneni bruit, Allen’s test, bilateral blood pressure) 2003, Rayan 1998,
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