DDx
Diagnostic Considerations
These include the following:
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Cervical myelopathy
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Cervical radiculopathy
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Double crush syndrome (thoracic outlet syndrome and compression at another distal or proximal site)
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Paget-von Schroetter syndrome, effort syndrome (spontaneous venous thrombosis, primary deep venous thrombosis of the upper extremity)
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Pancoast (apical lung) tumor
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Shoulder tendonitis, bursitis, impingement [16]
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Shoulder (glenohumeral) instability
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Raynaud syndrome
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Ulnar neuropathy (cubital tunnel syndrome, Guyon canal syndrome)
Differential Diagnoses
Media Gallery
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Progressive postural decompensation with neurovascular compression. A: Normal resting posture. B: Shoulder protraction beginning; the sternomastoid muscles are shortening, drawing the head anteriorly and inferiorly. C: Advanced deformity with adaptive shortening of scalene and pectoralis minor muscles. Also note narrowed costoclavicular space (ribs 1-5 have been relatively elevated). Neurovascular compression is evident at all 3 sites.
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Scalene focal (left) and regional (right) stress tests for thoracic outlet syndrome. Both tests can be easily combined to enhance the stress effect (may be helpful in mild cases).
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Pectoral focal (left) and regional (right) stress tests for thoracic outlet syndrome.
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Stretching technique for the pectoralis minor muscle. Left: The patient has taken the slack out of the muscle. Center: He then rotates the body away from the side being stretched, increasing traction. Right: Maximum rotation and stretch effect are achieved slowly. Image courtesy of The Journal of the American Osteopathic Association
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Sagittal plane posture of patient with thoracic outlet syndrome before (left) and after (right) treatment. Notice the release of the pelvis that occurred with the reduction in hyperlordosis, which allowed the shoulder girdle to drop back and open the thoracic outlet. Image courtesy of The Journal of the American Osteopathic Association
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Myofascial release technique for the scalene muscles. Left: Side-lying approach. Right/top: Supine approach with pillow under thorax. Right/bottom: Supine approach with head extended off the table and supported by the operator's knees. Image courtesy of The Journal of the American Osteopathic Association
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Stretching technique for the scalene (anterior and middle) muscles. Left: The arm on the side to be stretched is secured down (hooked under the seat) to allow more control and effective stretch. Center: The opposite hand wraps partially around the head for good control to assist with the stretch. Right: After proceeding as far as tolerated, the patient leans the whole trunk away from the side being stretched, creating additional traction (downward) on the muscle by the arm that is secured. Image courtesy of The Journal of the American Osteopathic Association
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Algorithm for the treatment of nonprogressive thoracic outlet syndrome (TOS). Anti-inflammatory medication, muscle relaxants, and activity modifications all are used as indicated and tolerated in all cases. Values for very severe TOS are greater than those for severe TOS, and the patient probably should be referred for surgical evaluation.
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