Thoracic Outlet Syndrome

What Is Thoracic Outlet Syndrome (TOS)? Causes and Symptoms

Thoracic Outlet Syndrome (TOS) is a clinical condition characterized by a group of upper extremity signs and symptoms resulting from the compression of the neurovascular bundle (the brachial plexus, and the subclavian artery and vein) as it passes through the thoracic outlet region. This anatomical site is enclosed by the anterior and middle scalene muscles, the clavicle, and the first rib. The thoracic outlet is also described as the space extending from the supraclavicular fossa to the axilla. TOS is considered a potentially disabling condition.

There are various causes of TOS, which can be broadly categorized as:

• Congenital Factors: These are abnormalities present at birth.
  • Cervical ribs or an anomalous first rib are common congenital causes. Cervical ribs have a prevalence of 1–2% in the general population and are a risk factor for developing both neurogenic (nTOS) and arterial (aTOS) TOS. About 20% of nTOS cases are attributed to cervical ribs.
  • Other congenital factors include C7 transverse process abnormalities, fibrous bands between the transverse process of C7 and the first rib, supernumerary ribs, anomalies of scalene muscle insertion, and exostosis of the first rib.
• Traumatic Factors: These are injuries that can lead to TOS.
  • Whiplash injuries and falls are common traumatic causes.
  • Clavicular fracture and first rib fracture can also contribute to TOS. Trauma can lead to hemorrhage, hematoma, displaced fractures, and the development of fibrosis that can compress the neurovascular structures.
• Functionally Acquired Factors: These develop over time due to certain activities or conditions.
  • Active and vigorous repetitive sport- and/or work-related activities can cause hypertrophy of muscles, such as the scalene muscles or pectoralis minor, leading to compression. vTOS is more common in athletes and manual workers performing vigorous activity.
  • Postural disorders and scapular girdle dysfunction may lead to narrowing of the costoclavicular angle, resulting in compression.
• Other acquired causes include consolidation defects of the first rib and clavicle, Pancoast tumor, hereditary multiple exostosis, and osteochondromas.

The symptoms of TOS vary depending on whether nerves, arteries, or veins are primarily compressed. TOS is classified into neurogenic (nTOS), arterial (aTOS), and venous (vTOS) based on the pathophysiology.

• Neurogenic TOS (nTOS): This is the most common type, accounting for 90–95% of cases. Symptoms arise from compression or irritation of the brachial plexus nerves and can include:
  • Pain in the neck, shoulder, arm, or hand. Pain may be diffuse and non-dermatomal.
  • Paresthesia, described as numbness and tingling, is a hallmark symptom. This often occurs in the arm and hand, particularly in the distribution of the affected nerve roots. Lower plexus (C8-T1) compression typically causes paresthesia in the fourth and fifth digits.
  • Weakness in the arm or hand. Chronic nTOS may lead to muscle weakness and atrophy, such as in the thenar, hypothenar, and interossei muscles (Gilliatt-Sumner hand).
  • Other reported symptoms include upper extremity heaviness, neck pain, trapezius pain, shoulder and/or arm pain, supraclavicular pain, chest pain, and occipital headache.
• Arterial TOS (aTOS): This is the least common type, making up 1–2% of cases. It results from compression of the subclavian artery and can present with:
  • Pallor (paleness), pulselessness, and coldness of the affected upper extremity.
  • Pain and weakening of the radial pulse with large arm movements.
  • A decreased blood pressure in the affected arm (greater than 20 mm Hg compared to the other arm).
  • In rare instances, multiple small infarcts in the hand and fingers due to embolization may occur.
• Venous TOS (vTOS): This type accounts for 3–5% of cases and is due to compression of the subclavian vein. Symptoms typically include:
  • Upper extremity swelling.
  • Venous engorgement (prominent veins).
  • Cyanosis (bluish discoloration) in the distal arm.
  • Feelings of arm heaviness.
  • Pain. Symptoms often have an acute onset.

Anatomy of the Thoracic Outlet

The anatomy of the thoracic outlet is crucial to understanding Thoracic Outlet Syndrome (TOS), as TOS results from the compression of the neurovascular bundle in this region. The thoracic outlet is the anatomical area crossed by the brachial plexus, and the subclavian artery and vein as they pass from the neck towards the axilla and upper limb. This area extends from the supraclavicular fossa to the axilla.

The neurovascular bundle courses through three primary anatomical spaces where compression can occur:

• Triangle of the scalenes (Interscalene triangle): This is the most medial and clinically important of the three passageways. It is bordered anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and the base is formed by the first rib.
  • The trunks of the brachial plexus and the subclavian artery pass through this triangle.
  • The subclavian vein passes anterior to the anterior scalene muscle and does not typically enter this compartment.
  • Compression within this space most frequently involves the brachial plexus and the subclavian artery.
  • Anatomic variations of the scalene muscles, the presence of the scalenus minimus muscle, or osseous abnormalities like a cervical rib can cause compression within the scalene triangle.
• Costo-clavicular space: Located just distal to the interscalene triangle, this space is outlined anteriorly by the middle third of the clavicle and the subclavius muscle, postero-medially by the first rib and the aponeurosis of the subclavian muscle, and posterolaterally by the upper border of the scapula.
  • The divisions of the brachial plexus, and both the subclavian artery and subclavian vein traverse this compartment.
  • This space is most frequently involved in the compression of the subclavian vein. Narrowing of this space can result from scapula depression or "drooping".
• Subpectoral space (Subcoracoid space): This is the most lateral of the three spaces, located beneath the coracoid process just deep to the pectoralis minor tendon. It is bordered anteriorly by the tendon of the pectoralis minor muscle and the coracoid process, and posteriorly by the thoracic wall (specifically the 2nd to 4th ribs).
  • The cords of the brachial plexus, the second part of the axillary artery, and the axillary vein are contained within this space. The subclavian artery and vein continue through this space as the axillary artery and vein.
  • The entire brachial plexus may be compressed at this level.

Role of the Scalene Muscles: The anterior and middle scalene muscles are crucial in the anatomy of the thoracic outlet, particularly in forming the borders of the interscalene triangle. The brachial plexus trunks and subclavian artery pass between these two muscles. Hypertrophy of these muscles, often due to repetitive activities or trauma, can narrow the interscalene triangle and lead to compression of the brachial plexus and/or the subclavian artery, resulting in neurogenic or arterial TOS. The anterior scalene muscle also has the subclavian vein passing anterior to it, and its hypertrophy or spasm can indirectly contribute to venous symptoms as well.

Brachial Plexus Compression: The brachial plexus, formed by the anterior rami of cervical nerve roots C5-C8 and thoracic nerve root T1 (with contributions from C4 and T2), supplies nerve fibers to the thorax and upper limb. Compression of the brachial plexus is the primary issue in neurogenic TOS (nTOS), which is the most common type of TOS. This compression most often occurs within the interscalene triangle but can also happen in the costoclavicular space or beneath the pectoralis minor tendon in the subcoracoid space. Anomalous structures such as cervical ribs, anomalous muscles (like a supernumerary scalene muscle), and fibrous bands can further constrict these spaces and increase the likelihood of brachial plexus compression. Repetitive trauma to the plexus elements, particularly the lower trunk (C8-T1), is also thought to play a role in the pathogenesis of nTOS.

Causes and Risk Factors

Several factors can contribute to the development of Thoracic Outlet Syndrome (TOS), increasing an individual's risk. These can be broadly categorized as postural issues, repetitive activities, and anatomical variations.

Poor Posture is a significant risk factor for TOS. A forward head posture and rounded, sagging shoulders can narrow the thoraco-coraco-pectoral space, leading to compression of the neurovascular bundle. Proper posture, involving relative retraction of the shoulders, is important for increasing this space. Scapular girdle dysfunction and a dropped shoulder condition (where the scapula is depressed and/or downwardly rotated, and/or anteriorly tilted) can also contribute to TOS by altering the anatomy of the thoracic outlet. Narrowing of the costoclavicular angle due to postural disorders and scapular girdle dysfunction can result in compression of the neck vascular bundle. Maintaining proper cervical alignment and shoulder blade stability are important aspects of preventing postural contributions to TOS.

Repetitive Overhead Work and other strenuous activities are well-known risk factors for TOS. Active and vigorous repetitive sport- and/or work-related activities can lead to muscular hypertrophy, particularly of the scalene muscles and pectoralis minor muscle, which can compress the neurovascular structures passing through the thoracic outlet. Venous TOS (vTOS) is more common in athletes (e.g., volley, baseball, swimming, body-building) and manual workers who perform vigorous activity. Workers in occupations requiring high levels of overhead use should modify their activities. Even activities involving intensive computer use, mobilization of disabled patients (requiring repeated efforts of the upper limbs in an abducted position), and other repetitive stress injuries can contribute to the development of TOS. Heavy lifting should be avoided with the affected extremity as it can further decrease the size of the thoracic outlet and increase the load on neurovascular structures.

Anatomical Variants play a crucial role in predisposing individuals to TOS.

• Cervical ribs are a congenital abnormality with a prevalence of 1–2% in the general population. They are a risk factor for developing both neurogenic TOS (nTOS), accounting for about 20% of nTOS cases, and arterial TOS (aTOS), as they can compress the subclavian artery. Cervical ribs or prominent "peaked" C7 transverse processes can be identified on cervical spine and chest x-rays.
• An anomalous first rib is another congenital factor that can contribute to TOS.
• Other congenital variations include fibrous bundles between the transverse process of C7 and the first rib, supernumerary ribs, and anomalies of scalene muscle insertion. A supernumerary scalene muscle can also contribute to compression within the interscalene triangle.
• Exostosis of the first rib is another congenital factor.

Beyond congenital factors, acquired abnormalities such as consolidation defects of the first rib and clavicle, and muscular hypertrophy due to physical or professional repetitive activities involving lifting weights are also considered causes. Traumatic events like whiplash injury or a fall on an outstretched arm can also lead to acute TOS symptoms.

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Why Physiotherapy is Essential

Physiotherapy is a cornerstone of the initial, non-surgical treatment for Thoracic Outlet Syndrome (TOS), particularly neurogenic TOS (nTOS), which accounts for 90–95% of cases. The primary goals of physiotherapy in managing TOS align with decompressing neural structures, improving posture, and strengthening scapular stabilizers.

Decompressing Neural Structures:

• Rehabilitative treatment aims to restore the width of anatomical spaces whose compression is at the basis of TOS. This can directly relieve pressure on the neurovascular bundle, including the brachial plexus, thereby alleviating symptoms like arm numbness and paresthesia.
• Neural mobilization techniques are crucial for improving the gliding of neural tissue in relation to its surroundings and minimizing tension and adhesion formation. These techniques can specifically target the brachial plexus in the costoclavicular or thoraco-coraco-pectoral space.
• Physiotherapy can involve techniques to restore the normal arthrokinematics of surrounding joints, further contributing to neural decompression.

Improving Posture:

• Poor posture, such as a forward head posture and rounded, sagging shoulders, can narrow the thoracic outlet. Physiotherapy programs emphasize postural education and corrections to address these issues.
• Encouraging a relative retraction of the shoulders increases the thoraco-coraco-pectoral space.
• Cervico-dorsal massage can help resolve contractures that contribute to poor posture.
• A 6-month physical therapy program often includes postural corrections as a key component.

Strengthening Scapular Stabilizers:

• Compromised sensorimotor control of the posterior parascapular muscles (rhomboids, serratus anterior, lower and middle trapezius) can lead to thoracic outlet narrowing. Physiotherapy includes sensorimotor control exercises to address these muscle imbalances and improve scapula control at rest and during arm elevation.
• Exercises often begin in gravity-assisted positions to ensure proper recruitment of lower scapular stabilizers.
• The focus is on muscular endurance rather than strength in the initial stages.
• Restoring scapula control and movement is a main component of rehabilitation, particularly in cases with a dropped shoulder condition. Exercises aim to achieve a "neutral" scapula position with proper muscle activation.
• Static reinforcement of the muscles that open the strait (thoracic outlet) is a key point of rehabilitative treatment.

Evidence of Effectiveness:

• Initial management of TOS is usually conservative, with dedicated physical therapy.
• A multimodal approach including patient education, TOS-specific rehabilitation, and drug therapies has shown positive results in 60–70% of nTOS cases.
• Physical therapy is associated with significant symptom improvement in 50 to 90% of patients.
• A structured rehabilitation program is associated with a statistically significant better outcome than no rehabilitation.
• Patients with mild TOS are generally expected to improve within 6 weeks of a physical therapy program.
• Studies have found that good or very good results were achieved in 76 to 100% of disputed neurogenic TOS patients at short-term follow-up with conservative treatment and 59 to 88% after at least one year.

Adjunctive Strategies:

• Patients are educated that activities like overhead activity, heavy lifting, and repetitive motions can aggravate symptoms and hinder recovery.
• A 6-month physical therapy program can consist of home-exercises, stretching, postural corrections, and muscle recruitment patterns, primarily focusing on the neck and shoulder.
• Other manual therapy techniques, such as cervicothoracic and first rib mobilization, and scalene and pectoral muscle stretches, may be added to the rehabilitation program.
• Kinesiotherapy aims to restore the balance between muscles opening and closing the thoracic egress.
• Breathing exercises can help lessen the overload of scalene muscles and lower the first rib.

In summary, physiotherapy is essential for TOS because it provides a non-invasive approach to decompress the neurovascular structures, including the brachial plexus responsible for arm numbness. By improving posture and strengthening the scapular stabilizers, physiotherapy aims to correct the underlying biomechanical factors contributing to the compression and alleviate symptoms, often proving effective as a first-line treatment before surgical options are considered. A physiotherapist specialized in TOS treatment guides this process, adapting the therapy based on the patient's symptom status.

Prognosis: Recovery Timeline

Conservative rehabilitation is often the first-line treatment for Thoracic Outlet Syndrome (TOS), and many individuals experience significant symptom reduction through these methods. While the exact timeline can vary based on the individual and the specifics of their condition, the sources provide some insights into the expected recovery:

• Symptom Improvement: A 6-month physical therapy program, including home exercises, stretching, postural corrections, and muscle recruitment patterns focused on the neck and shoulder, can alleviate symptoms associated with TOS. Generally, patients with mild TOS are expected to improve within 6 weeks.
• Structured Rehabilitation Outcomes: A study found that of patients in a TOS-specific rehabilitative program, 67% had improved symptoms at the last available follow-up visit (T2). This highlights the potential for positive outcomes with a dedicated program.
• Timeline for Changes: Clinical data suggests that patients can reliably achieve a change in their scapula resting position by 6 weeks of rehabilitation. Alterations in both shoulder girdle strength and scapula motion through range may be seen by 12 weeks of rehabilitation. Concurrent with these physical changes is usually a gradual improvement in the patients’ signs and symptoms and an improvement in their functional state.
• Subjective and Objective Improvement: It is reasonable to expect some subjective and objective improvement in symptoms by six to eight weeks if the rehabilitation program is going to benefit the patient.
• Variability in Recovery: Some patients may complete their program and achieve normal strength and scapula measurements by 12 weeks, others may take up to 6 months, and some may plateau or not complete the program.
• Success Rates: Reviews of the literature on conservative treatment for TOS have reported good or very good results in 59 to 88% of disputed neurogenic TOS patients after at least one year. Another review indicated that physical therapy is associated with significant symptom improvement in 50 to 90% of patients. A multimodal approach including patient education, TOS-specific rehabilitation, and drug therapies has shown positive results in 60–70% of cases.

Regarding chronic nerve compression, the recovery timeline with conservative rehabilitation may be longer and requires an individualized approach to address the specific dysfunctions identified during a thorough clinical examination. Negative prognostic indicators for conservative therapy include the length and severity of TOS symptoms, suggesting that more chronic and severe cases may take longer to respond. If symptoms persist after at least 3–6 months of rehabilitation and patients are still experiencing disability, a surgical approach might be considered. Similarly, another source suggests that if the patient's condition is refractory to a trial of 4–6 months of conservative management, more invasive therapies such as surgery are often considered.

In summary, while a 6–12 week timeframe for symptom reduction with conservative rehabilitation is a reasonable expectation for many TOS patients, especially those with milder and more recent onset symptoms, individuals with chronic nerve compression may require a more prolonged course of therapy, and their outcomes can be influenced by various factors including the duration and severity of their condition. Ongoing reevaluation and adaptation of the therapy are crucial, dictated by the patient's symptom status.

Physiotherapy Treatment Plan

A comprehensive physiotherapy approach begins with a thorough evaluation to identify the specific underlying causes of neurovascular compression.

Biomechanical Assessment

Evaluate posture, cervical/thoracic mobility, and neural tension is a critical first step in developing an individualized treatment plan.

• Evaluate Posture: As discussed previously, poor posture, such as a forward head posture and rounded shoulders, can contribute to narrowing of the thoracic outlet. The assessment should identify postural deviations like a dropped shoulder condition (scapula depression, downward rotation, anterior tilt). Source describes methods for measuring scapula elevation/depression and asymmetry.
• Evaluate Cervical/Thoracic Mobility: Restrictions in the cervical and thoracic spine can influence the mechanics of the thoracic outlet. The assessment would include evaluating the range of motion in these areas. Techniques like cervico-dorsal massage can be used to address contractures. Source illustrates costovertebral and costotransversal joint mobilizations.
• Evaluate Neural Tension: Increased neural tension indicates restricted gliding of the neural tissues. Assessment involves tests like the upper limb tension tests (ULTTs), which you mention, designed to reproduce symptoms by stretching the brachial plexus.

Nerve Gliding Exercises

Your inclusion of "Upper limb tension tests (ULTTs), median/ulnar nerve flossing" in the treatment plan is essential for addressing neural mobility, which is often impaired in TOS.

• As previously mentioned, neural mobilization techniques aim to improve the gliding of neural tissue in relation to its surroundings and minimize tension and adhesion formation.
• These exercises, sometimes referred to as nerve flossing or gliding, can be modified to emphasize different parts of the brachial plexus.
• It's crucial that these exercises are performed in a pain-free manner, and any increase in symptoms should prompt a decrease in repetitions or intensity. You previously mentioned a potential progression up to 100 repetitions as tolerated [Me].

Postural Correction

Postural exercises can help to restoring proper alignment and decompressing the thoracic outlet.

• Chin tucks help correct forward head posture.
• Scapular retraction exercises encourage the shoulders to move back, increasing the thoraco-coraco-pectoral space. This is a key element in the rehabilitation program, aiming for a "neutral" scapula position.
• Pectoral stretches, such as the corner stretch for pectoralis major and the supine stretch for pectoralis minor, address the shortening of these muscles that can contribute to a narrowed thoracic outlet.

Strengthening

Strengthening exercises are crucial for restoring scapular control and stability, which is a cornerstone of conservative management for TOS.

• Lower trapezius rows help strengthen the lower fibers of the trapezius, which are important for scapular depression and upward rotation.
• Serratus anterior punches (or protraction exercises) target the serratus anterior muscle, which is vital for scapular upward rotation and stabilization against the rib cage. Weakness in serratus anterior is often observed in TOS.
• As previously discussed, the rehabilitation program emphasizes establishing normal scapula muscle recruitment and control before progressing to loaded exercises. The focus is often on muscular endurance rather than strength initially. Other important muscles for strengthening include the upper and middle trapezius.

Prevention Strategies

• Avoiding Prolonged Overhead Work and Repetitive Motions:
  • The sources indicate that repetitive overhead activities and vigorous, repetitive sport- or work-related activities can be a functionally acquired cause of TOS. Patients with TOS are often advised to avoid overhead activity, heavy lifting, and repetitive motions as these can aggravate their symptoms.
  • Workers whose occupation requires high levels of overhead use should modify their activities as necessary.
  • Activities involving intensive computer use, mobilization of disabled patients (involving repeated efforts of the upper limbs in an abducted position), and other work-related injuries can contribute to the development of TOS. Therefore, modifying these activities and taking breaks can be a preventative measure.
• Strengthening Mid-Back Muscles (Scapular Stabilizers):
  • As discussed previously, strengthening the mid-back muscles, particularly the middle and lower trapezius and rhomboids (the scapular retractors), is crucial for maintaining good posture and a more open thoracic outlet. These muscles counteract the tendency for rounded shoulders, which can narrow the thoraco-coraco-pectoral space.
  • Rehabilitation programs for TOS emphasize strengthening muscles that open the strait, which includes the scapular stabilizers. Restoring scapula control and movement is a main component of rehabilitation and can be considered a preventative approach for individuals at risk.
  • Exercises aimed at strengthening and lengthening postural muscles of the back and shoulder have demonstrated effectiveness in reducing pain associated with TOS. Maintaining strength in these muscles may help prevent the onset of TOS.
• Ergonomic Desk Setup and Postural Considerations:
  • Poor posture is identified as an acquired factor that can lead to narrowing of the costoclavicular angle, resulting in compression of the neurovascular bundle. A forward head posture and rounded, sagging shoulders are common in TOS and can be influenced by desk setup.
  • While the sources don't provide specific instructions for ergonomic desk setup, they strongly emphasize postural education and correction as a key element in both the treatment and likely the prevention of TOS.
  • Maintaining proper posture while working, especially for prolonged periods, is important. This can involve ensuring:
    • Proper chair height and support for the lumbar spine.
    • The computer screen is at an appropriate height to avoid a forward head posture.
    • The keyboard and mouse are positioned to allow for neutral wrist and elbow positions, reducing strain.
    • Regular breaks to stretch and change positions, preventing prolonged static postures that can contribute to muscle imbalances and compression.

FAQs

• Can TOS cause permanent damage?
  • Yes, TOS can potentially lead to permanent damage, especially if left untreated. Early recognition and diagnosis for each subtype of TOS are crucial to prevent long-term sequelae, specifically chronic upper extremity pain and severe disability.
  • For vascular TOS (both arterial and venous), surgical management is indicated because of the potentially limb-threatening complications that can result from arterial or venous compromise. Patients with subclavian artery compression can present with multiple small infarcts of the hand and fingers owing to embolization, indicating potential for permanent damage if not treated.
  • Adult patients presenting with features of TOS necessitate a low threshold for imaging, as delay in treatment can lead to irreversible changes and chronic pain.
  • In true neurogenic TOS, which is rare, there can be advanced atrophy. While 'huang2004.pdf' notes that dramatic improvement may not always follow surgical plexus decompression in true TOS, the presence of atrophy suggests potential for lasting effects.
• Is surgery necessary?
  • Surgery is not always necessary for TOS. The initial management of TOS is usually conservative. This includes dedicated physical therapy, addressing muscle imbalance, postural abnormalities, and neural mobilities.
  • A multimodal conservative approach, including patient education, TOS-specific rehabilitation, and drug therapies, has shown positive results in 60–70% of neurogenic TOS (nTOS) cases.
  • However, surgery is considered if symptoms persist after at least 3–6 months of rehabilitation and patients are experiencing some degree of disability.
  • Surgery is generally indicated for vascular TOS (arterial and venous) due to the potential for serious complications. This is often due to structural abnormalities that may not respond to conservative treatment. Indications for vascular surgery include persisting disabling symptoms that interfere with daily life activities, or with vascular complications like stenosis, thrombosis, or aneurysms.
  • Surgery may also be considered for true neurogenic TOS, especially when conservative management is unhelpful and there is advanced atrophy. For the nonspecific or disputed type of nTOS, surgery is usually offered as a last resort after prolonged conservative management has failed.
• Does yoga help TOS?
  • Yoga often involves stretching, postural work, and breathing exercises, which are all components of conservative management for TOS. Stretching of scalene and pectoral muscles, postural correction (like scapular retraction and chin tucks), and breathing exercises are recommended in physiotherapy for TOS.
  • Therefore, certain aspects of yoga that focus on these elements might be beneficial for some individuals with TOS, but there is no direct evidence in these sources to confirm this. It would be prudent to consult with a healthcare professional or a physiotherapist experienced in treating TOS before using yoga as a primary treatment.
• Can massage worsen symptoms?
  • Massage is mentioned as a component of conservative rehabilitative treatment for TOS. Cervico-dorsal and scapular girdle massage is suggested to resolve contractures.
  • Precaution: in all patients with TOS, therapists must warn the patient to be alert for any alteration or aggravation of distal symptoms, swelling, color changes, or temperature. It specifically notes that over-retraction of the scapula may create a relative entrapment of the neurovascular structures behind the pectoralis minor, which could potentially be exacerbated by certain massage techniques if not applied carefully.
  • Therefore, while massage can be a helpful part of TOS management, it is important that it is performed by a therapist experienced in treating TOS and that patients communicate any worsening of symptoms. The specific techniques used should be appropriate for the individual's condition, and excessive or incorrect pressure or manipulation could potentially aggravate symptoms in some cases, particularly in those with true structural compression.

Ready to Reduce Nerve Compression?

Our Specialized Approach to Rehab

Our programs include:

• Neural dynamic techniques to improve nerve mobility
• Dry needling for scalene muscle release
• Ergonomic workstation assessments

Book Your Assessment Today:

• Phone: 905-669-1221
• Location: 398 Steeles Ave W #201, Thornhill, ON L4J 6X3
• Online Booking: www.vaughanphysiotherapy.com

Ready to Reduce Nerve Compression?

Our Specialized Approach to Rehab for Thoracic Outlet Syndrome (TOS)

You're taking a proactive step in addressing potential nerve compression related to Thoracic Outlet Syndrome (TOS). Our specialized rehabilitation approach is designed to target the underlying factors contributing to your symptoms, drawing on established principles of TOS management.

Our programs include:

• Neural dynamic techniques to improve nerve mobility:
  • TOS is characterized by compression of the neurovascular bundle, which includes the brachial plexus nerves, as they pass through the thoracic outlet region. Neural mobilization techniques are a key component of conservative management, aiming to address this compression by improving the gliding and movement of the nerves.
  • These techniques can be specifically modified to emphasize different parts of the brachial plexus as it passes through potential compression sites like the interscalene triangle or costoclavicular space.
  • It's important to note that neural mobilizations should be performed in a pain-free manner, and any increase in symptoms should be addressed by adjusting the exercises.
• Dry needling for scalene muscle release:
  • The anterior and middle scalene muscles are key anatomical structures that form part of the thoracic outlet. Hypertrophy or tightness of these muscles can contribute to compression of the neurovascular bundle, particularly in the interscalene triangle.
  • While the sources don't specifically mention "dry needling," they do discuss interventions targeting the scalene muscles. For example, injection therapy with local anesthetics or botulinum toxin A into the anterior scalene muscle has been shown to provide temporary symptomatic relief and can even be a positive surgical prognostic factor.
  • Releasing tension in the scalene muscles, through techniques like dry needling (which aims to address trigger points and muscle tightness), can help restore the width of the anatomical spaces in the thoracic outlet and alleviate nerve compression.
• Ergonomic workstation assessments:
  • Functionally acquired causes, such as active and vigorous repetitive sport- or work-related activities, can contribute to TOS. Our conversation history highlighted the importance of ergonomic desk setup and postural considerations in preventing and managing TOS.
  • Poor posture, such as forward head posture and rounded shoulders, can narrow the thoracic outlet and increase compression.
  • An ergonomic workstation assessment helps identify and address these postural factors by ensuring proper chair height and support, appropriate computer screen and keyboard/mouse positioning, and recommendations for regular breaks and stretching.
  • Postural education and correction are key components of rehabilitative treatment, aiming to restore the balance between muscles and alleviate neurovascular strain. Modifying aggravating activities and adopting long-lasting postural and habitual lifestyle modifications are positive prognostic factors in conservative therapy.

Book Your Assessment Today: Taking timely action is crucial in managing TOS and preventing potential long-term issues like chronic pain and disability.

• Phone: 905-669-1221
• Location: 398 Steeles Ave W #201, Thornhill, ON L4J 6X3
• Online Booking: www.vaughanphysiotherapy.com

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