Thoracic outlet syndrome is a upper thoracic and/or lower cervical disorder caused by thoracic outlet compression of the brachial plexus and/or the subclavian vessels. Patients are frequently young, active, and healthy and they have seen multiple practitioners, had many scans and undergone misdiagnosis. Manifestations of thoracic outlet syndrome include neurogenic thoracic outlet syndrome, caused by compression of the brachial plexus, and vascular thoracic outlet syndrome. Estimates are that >90% of all thoracic outlet syndrome cases are of neurogenic origin, whereas approximately 3% to 5% are vascular.

1. At Sydney Muscle & Joint Clinic Penrith our physiotherapists that manage neurogenic thoracic outlet syndrome (compression of nerve tissue) find patients will present with a variety of symptoms of upper extremity weakness, numbness, paresthesias, and pain in a non-radicular distribution- often presenting as whole arm, hand and finger pain and numbness. Upper extremity heaviness is common with above-the-shoulder activities and symptoms can be present during normal upper limb daily activities as well as during sleep. In a systematic review it was found that symptom distribution in neurogenic thoracic outlet syndrome included upper extremity paresthesia (98%), neck pain (88%), trapezius pain (92%), shoulder and/or arm pain (88%), supraclavicular pain (76%), chest pain (72%), occipital headache (76%), and paresthesias in all five fingers (58%), the fourth and fifth fingers only (26%), or the first, second, and third fingers (14%).

1. During physical exam our physiotherapists will pay attention toward the position of the head, neck, and shoulder, looking for the presence of thoracic kyphosis or curvature in the mid back. Further, looking at the muscles in and around the palm can show atrophy of the abductor pollicis brevis and, to a lesser degree, the hypothenar musculature and the interossei. Palpation of the supraclavicular region may reveal tenderness, masses, or other abnormalities. Quality and location of pain with movements of the neck, shoulder, and upper limb should be recorded. Ruling in or out vascular thoracic outlet syndrome will be based on tests such as the Wright test, the Adson test, the most reliable being Roos test, or the elevated arm stress test.

1. At Sydney Muscle & Joint Physio Penrith we utilise evidence-based non-surgical treatment of thoracic outlet syndrome. This includes a typical protocol consisting of education, activity modification, and physical therapy with most patients experiencing symptomatic relief after at least 6 months of physical therapy. Non-surgical management is reported to be less successful in obese patients, in patients who are on workers’ compensation, and in patients with double-crush neurologic pathology involving the carpal or cubital tunnels.

   Pain control strategies include anti-inflammatory medications, muscle relaxants, transcutaneous electrical nerve stimulation, and injections. Education should include clarifying goals of treatment is critical for patient outcome. Patient education focuses on relaxation techniques, postural mechanics, and weight and nutritional control. Physical therapy at Sydney Muscle & Joint Physio Penrith focuses on a short period of limiting repetitive overhead stress, dynamic mobility of the thoracic spine and upper limbs and this involves range-of-motion exercises, and tendon and nerve gliding techniques. Strengthening of shoulder and scapula retraction muscles and trunk muscles will also have a positive influence on posture.

1. Individuals with thoracic outlet syndrome, the stability of the shoulder joint may be negatively affected by loose or laxity in the shoulder ligaments. Ligamentous laxity, also known as hypermobility, allows for increased movement in joints outside of the normal range of motion. In one study, 54% of individuals who presented with hypermobility also had symptoms of thoracic outlet syndrome. Due to hypermobility in most individuals with thoracic outlet syndrome stretching should not be utilised as an intervention.

   When looking at the strength and length of individuals with thoracic outlet syndrome, muscle weakness and muscle tightness can cause a range of issues. A common feature exhibited by individuals with thoracic outlet syndrome is a flexed head position, depressed and anteriorly shifted shoulder, and protracted scapula. This abnormal shoulder position, combined with 90° of abduction or flexion (as is commonly observed with those whose occupations require reaching, especially overhead, and repeated loading), could lead to a decrease in the costoclavicular space, increased friction of the neurovascular bundle in the subpectoral bundle, and a shortening of the sternocleidomastoid. The shortened sternocleidomastoid may cause the scalenes and pectoralis muscle groups to shorten, leading to improper head and neck alignment and postural dysfunction.

   ​Our Penrith physiotherapy team recommends the following in regards to exercises for thoracic outlet syndrome:

   • initially incorporate shoulder movements ranging from 0 to 30° flexion, while maintain approximately 40° horizontal abduction.
   • progress to shoulder movements that incorporate 45 to 90° flexion and functional overhead tasks.
   • initially target scapular muscles (e.g., middle and lower trapezius and rhomboids) in an effort to stabilise the shoulder.
   • as patients progress, the strengthening of the serratus anterior musculature is important, but horizontal adduction should be minimised to prevent further injury.