In today’s article, we are going to discuss one of the common syndromes i.e., THORACIC OUTLET SYNDROME. As you can see in the title, we will learn about this syndrome along with the thoracic outlet syndrome exercises, its causes, clinical features, as well as its treatment. But to completely understand this syndrome, first, have a look at what is the thoracic outlet and its anatomy.
ANATOMY OF THORACIC OUTLET
A thoracic outlet is a space between the first rib, the clavicle, and the scalene muscle. The thoracic outlet is present in the neck’s lower part, just above and behind the clavicle.
In the thoracic outlet, there are neurovascular bundles comprising the subclavian artery and vein, axillary artery and vein, and brachial plexus.
WHAT IS THORACIC OUTLET SYNDROME (TOS)?
Thoracic outlet syndrome (TOS) is a condition where there is compression of the neurovascular bundles comprising the subclavian artery and vein, axillary artery and vein, and brachial plexus at the thoracic outlet.
The above structures are liable to be compressed when this space gets narrowed either due to hypertrophy of the existing muscles or due to any other causes like congenital, trauma, etc. The space at the thoracic outlet or inlet when it is less than adequate, makes the neurovascular structures enter into the upper limbs via this space, to undue pressure.
SITES OF COMPRESSION
The sites where there can be compression are either supraclavicular, subclavicular, or infraclavicular.
- SUPRACLAVICULAR: At the inter scalene triangle between the anterior scalene muscles.
- SUBCLAVICULAR: At the interval between the 2nd thoracic rib, clavicle, and subclavius.
- INFRACLAVICULAR: Beneath the enclosure formed by the coracoid process, pectoralis minor, and costocoracoid membrane.
- RARE CAUSES: Scissor-like encirclement of the axillary artery by the median nerve.
CONTRIBUTING FACTORS
DYNAMIC FACTORS
Arm when in full abduction, pulls up the artery by 180 degrees which may cause compression in the short retroclavicular space.
STATIC FACTORS
- Vigorous occupation increases the muscle bulk and thereby decreases the space.
- Inactive occupation decreases the muscle bulk and thereby increases the space.
- Arteriosclerosis
- Anomalies of the first thoracic rib
- Malunion or nonunion of the fracture clavicle.
- Congenital cervical rib decreases the inter scalene space and thereby decreases the retro clavicular space.
- Miscellaneous-
- Tumors arising from the upper lobe of the lung
- Cervicothoracic scoliosis
- Abnormal variations of the scalene muscles
CLINICAL FEATURES
This syndrome poses two main problems. The first one relates to the compression of major vessels and the second to the compression of nerves.
VASCULAR PROBLEMS:
Vascular problems can be either due to arterial compression or venous compression.
During the arterial compression, which is mild in the early stages, the patient complains of numbness of the whole arm with rapid fatigue during overhead activities. If there is significant compression, then the patient will complain of cold, cyanosis, pallor, and Raynaud’s phenomenon.
During the venous compression, the limb will be swollen and discolored after exercises which disappears slowly with rest.
NEUROGENIC PROBLEMS:
This involves the C8 T1 segment (Klumpke’s paralysis). The patient will complain of paraesthesia along the medial aspect of the arm, hand, little, and ring fingers. There is a weakness of the hand also.
COMPLICATIONS OF TOS
Subclavian artery compression –> results in post-stenotic dilatation –> statis favors thrombosis –> the thrombi break and migrate distally causing embolization –> this results in the distal artery blockade causing ischemia and gangrene of the upper limbs.
INVESTIGATIONS
- X-Ray neck- To rule out intrinsic causes like cervical spondylosis, cervical rib, etc.
- Nerve conduction studies- Difficult to determine the nerve conduction studies through the thoracic outlet, but its biggest value is to rule out problems like entrapment, e.g., the ulnar nerve at the elbow, wrist, etc.
TREATMENT
- CONSERVATIVE TREATMENT- It consists of rest and pain killers.
- SURGICAL TREATMENT- It is indicated in gangrene and post-stenotic dilatation.
- Methods:
- Removal of first thoracic rib- This is the most effective treatment as it deals with both supraclavicular and infraclavicular factors.
- Removal of cervical rib- If this is the cause of the compression.
- Scalenotomy- It is indicated in scalenus anticus syndrome.
- Methods:
PHYSIOTHERAPY MEASURES
- THERMOTHERAPY- For pain relief and relaxation.
- Manipulate and mobilise and relax 1st rib and clavicular, scapular, pectoral muscles.
- STRENGTHENING EXERCISES– Strengthen the shoulder girdle muscles and stretch scalene muscles.
- RESTORATION OF NORMAL POSTURE– Proper postural changes and correct faulty postures.
THORACIC OUTLET SYNDROME EXERCISES
Before you begin your exercises-
- Warm your muscles before stretching by heating your neck and shoulder area with a warm shower or heating pad for about 10-15 minutes until you feel warm.
- Stretch gently- Do not overstretch your muscles. You should only feel a pull in your muscles and not the pain.
- Hold your stretch.
- If your hand feels cold, numb, or begins to tingle, stop stretching.
By keeping the above points in mind, start these thoracic outlet syndrome exercises which we are going to discuss now-
Thoracic Outlet Syndrome Exercises:
- Look straight ahead while sitting or standing.
- Bend your right ear towards your right shoulder.
- Hold the stretch for 20 sec.
- Repeat with the other side as well.
- Do it 10 times on each side 2 times a day.
- Begin in a quadruped position ( Both legs and hands on the ground).
- Take your one hand up to the air, opening your chest to the sky while maintaining your weight on the other hand.
- Make your eyes follow your hand all the time.
- Get back your hand to the starting position and do this 10 times.
- Repeat with the other side as well.
- Try to maintain a neutral spine and do controlled and slow movements.
- Lie down in a prone position ( i.e., on your abdomen).
- Extend your both legs as well as arms.
- With palms facing toward the floor, make a wide controlled arc with your hands starting from the hip and ending at the top of your head.
- Elbow should remain in extension position throughout the movement.
- Chin stays tucked and abs engaged to avoid arching of the back.
- Repeat this movement 10 times.
- Start with your elbows low.
- Lean your body weight forward until you feel a stretch in front of your shoulder or chest.
- Now do the same with elbows at shoulder height and then slightly more towards the ceiling.
- Do this stretch 5 times with each position.
NOTE: Do not overstretch your muscles.
- Raise your arms to shoulder height with the elbows bent.
- Your palms should face forward.
- Squeeze both your shoulder blades together and hold for 10 seconds.
- Do it 10 times.
- Stand straight and put your hands to the sides of your body.
- Your palms should face your body.
- Now shrug your both shoulders up and back.
- Repeat 10 times.
- Pull your chin back as you are trying to make a double chin.
- Hold there for 5-10 seconds and then relax,
- Repeat 10 times.
- Lie down on your abdomen.
- Put your hands on your sides.
- Lift your head as well as chest off the floor as you can.
- Hold for at least 5 seconds and then relax.
- Repeat 5-10 times.
How to correct your posture?
Try to sit tall when you are sitting or standing. Slouching causes the shoulders and neck to roll forward, and can also tighten the muscles in your back and shoulders,.
CONCLUSION:
In today’s article, we have seen one of the common but challenging conditions i.e., thoracic outlet syndrome (TOS). We have also discussed its clinical features, causes, complications, as well as treatment. The thoracic syndrome exercises which are mentioned above can be very helpful for treating this condition.
Please note to always consult your physiotherapist before doing any kind of exercise.
ALL THE BEST!