Physical Medicine and Rehabilitation for Thoracic Outlet Syndrome Treatment & Management

Physical Therapy

Modalities with deep heat (eg, therapeutic ultrasound), electric stimulation, superficial heat (eg, Hydrocollator packs), stretching exercises, postural correction exercises, and strength and endurance exercises are all useful or necessary components of thoracic outlet syndrome treatment. Ultrasound is the preferred modality, as it is capable of heating deep muscular and soft-tissue structures, which is essential to increase elasticity and facilitate effective stretching and/or manipulation, especially for the scalenes (see the first image below) and pectoralis minor muscles (see the second image below). Ideally, ultrasound should be performed immediately before the stretching or manual treatment, since the deep tissues cool (from 41-42°C back to 37°C) within 20-30 minutes.

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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Mobilization and manipulation procedures (often performed by an osteopathic physician) usually are indicated and necessary to release tight, contracted/restricted vertebral segments and soft tissue (myofascial) regions, especially the anterior/middle scalenes (see the first image below) and pectoralis minor muscle (see the second image below) entrapment sites. Ultrasonography has been used to identify the pectoralis minor and guide the manipulating hand as an aid for more precise targeting and effective manual release of the muscle. ^[6]

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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Spray and stretch with a vapo-coolant spray is an effective adjunct to the other modalities mentioned here. Note that the research-based scientific evidence for these modalities is limited.

Occupational Therapy

Work simplification and back protection techniques often are helpful. These educational tools are available from the occupational therapist, as well as from the physical therapist.

Essentially, there are no randomized, controlled trials demonstrating that specific treatment modalities are more effective than placebo. In general, research into thoracic outlet syndrome (TOS) and its treatment can be difficult for the following several reasons:

• If the etiology of the problem cannot be agreed upon, then focusing treatment becomes difficult.

• The proposed areas of pathophysiology and diffuse nature of symptoms are not easily amenable to surgery or other treatment modalities.

• Many patients with TOS have coexistent chronic pain syndrome with disability and depression.

Treatment of the chronic pain and disability can be a much more complex problem and involves employment of multiple disciplines with consideration for a biopsychosocial model of treatment. Patients with nonspecific TOS and suggestion of chronic pain syndrome with disability may do best with chronic pain treatment and treatment of psychological issues.

Additional issues of concern include the following:

• More advanced/severe TOS can result in functional loss of the upper extremity.

• Concomitant cervical degenerative joint/disc disease limits the neck range of motion (ROM) that is necessary to stretch associated soft tissue restriction and limit conservative treatment options (eg, physical therapy).

• Shoulder arthritis/bursitis/tendonitis can interfere with stretching of the pectoral muscles and limit the effectiveness of conservative therapy approaches.

• Manual treatment to the pectoral/chest wall muscles must be sensitive to overlying breast tissue and implants (prostheses) in female patients.

• Manual treatment must consider the proximity of the involved muscles to the brachial plexus. Vigorous stretching or manipulation of these structures may not be tolerated well and can aggravate symptoms. The phrenic nerve and accessory phrenic nerve overlie the anterior scalene muscle and also must be considered.

• Scalene nerve block has been used as a treatment and as a diagnostic test; however, this procedure is dangerous due to the close proximity of the brachial plexus to the scalenes (see Procedures for more details).

First rib resection has been advocated by many surgeons to treat thoracic outlet syndrome. Many also use scalenectomy, in combination with rib removal or as a second procedure, if the initial surgery is ineffective. ^[11] Resection of accessory ribs and fibrous bands should be performed, especially if observed to be tethering the plexus.

In cases where clavicular fracture is responsible for plexus compression, removal of hyperabundant callus may be necessary. Occasionally, resection of associated musculature is required, including the subclavius and infraclavicular soft tissue. Reduction of clavicular nonunion fragments and internal fixation (with pins) may be indicated.

Complications from surgical treatment have been devastating, especially brachial plexopathy (eg, injury to the long thoracic nerve with scapular winging). Generally, surgery is used as a last resort after a prolonged trial (ie, months) of conservative treatment.

Some authors have advocated breast reduction in extreme cases, where very large breasts obviously are adding uncontrollable weight loads to the anterior chest wall.

A study by George et al found that 3547 TOS operations were listed in the National (Nationwide) Inpatient Sample database as having been performed between 2010 and 2015, with the investigators estimating the total number of such surgeries in the United States for that period to have been 18,210. Of those operations counted, 89.2% were for neurogenic TOS. Patients had an overall mortality rate of 0.6%, with just 0.3% experiencing neurologic injury. The annual number of TOS surgeries rose during the 2010-2015 period, while the complication rate decreased. ^[22]

See the list below:

• Physical medicine and rehabilitation specialists (physiatrists) are generally familiar with thoracic outlet syndrome (TOS) and conservative treatment options. They usually are best positioned to implement and direct the therapy program, and they also have been trained extensively in electrodiagnosis, which may provide the best objective evidence for the disorder in its true neurogenic form. Neurologists are also capable diagnosticians for TOS.

• The image below depicts an algorithm for the treatment of nonprogressive thoracic outlet syndrome (TOS).

  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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• Some internists or cardiologists who specialize in peripheral cardiovascular disorders may be able to help with the diagnostic workup, especially when vascular or autonomic symptoms predominate. They also may be familiar with the use of medications to help control symptoms (eg, vasodilators, calcium-channel blockers). Rheumatologists can assist in ruling out connective tissue disorders or autoimmune diseases that might be associated with TOS or might be complicating the clinical picture.

• Thoracic and cardiovascular surgeons are the most likely surgical specialists to treat TOS; however, not all of these surgeons have an active interest or willingness to deal with the disorder. Occasionally, neurosurgeons can offer operative treatment for TOS patients.

• Plastic surgeons (or some general surgeons) may be used for reduction mammoplasty, when indicated.

• Anesthesiologists may be needed to perform diagnostic and therapeutic blocks.

• Orthopedists may be required to diagnose and treat concomitant shoulder joint pathology and other related disorders, such as complications from clavicular fractures.

See the list below:

• Osteopathic manipulation has been shown to be highly effective in treating thoracic outlet syndrome, especially in combination with vigorous stretching exercise. The most useful procedures involve a vigorous myofascial release to the scalenes and pectoral muscles (especially pectoralis minor). These techniques are applied most easily immediately following modality treatment with ultrasound, which heats the deep muscular structures and renders them more elastic and responsive to manipulation and stretching.

• All other areas of restriction or dysfunction also should be addressed and treated with manipulation, since even pelvic/sacral abnormality can influence the thoracic outlet. This abnormality is most obvious with unleveling, or a sacral tilt that shifts the thorax and places skeletal and muscular strain on the shoulder girdle region. Some orthoses, such as a heel lift, may be a useful adjunct in such cases.

• Injection of trigger points in associated muscular structures may be indicated and necessary. An injection of deep muscular structures, such as a scalene block, however, is dangerous (close proximity to brachial plexus) and should be avoided or performed by an anesthesiologist. Even so, a study by Torriani et al of diagnostic injections indicated that anesthetic can be safely injected into the anterior scalene muscle with ultrasonographic guidance (see Procedures). ^[21]