Additional Information - Thoracic Outlet Syndrome

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Clinical Presentation

Release-phenomenon

The symptoms occur with work activities above the horizontal plan. The symptoms only occur after the decrease or removal of the compression. The longer the compression, the longer the latency time.
Example: worsening of the symptoms when elevating the arm to do such things as blow dry one's hair or put something on a high shelf (when the arm is depressed again and the compression of the vessels is removed, the symptoms occur).

Physical presentation

• In abduction, patients with dropped shoulder TOS frequently demonstrate late and insufficient upward rotation of the scapula compared to the other side and/or to normal. This can often lead to a restriction of abduction range.
=> the deficit is due to inadequate shoulder girdle muscle control and reduced upward rotation of the scapula.
• In flexion, the same tendency for depression and downward rotation is seen but is often overshadowed by an obvious winging of the scapula due to serratus anterior insufficiency.

Management / Interventions

Scapula settings and control

In the treatment you first have to start with scapula settings and control.
This is important to establishing normal scapula muscle recruitment and control in the resting position. Once this is achieved then the program is progressed to maintaining scapula control while both motion and load are applied. The programme begins in lower ranges of abduction and is gradually progressed further up into abduction and flexion range until muscles are being retrained in functional movement patterns at higher ranges of elevation.

Control the humeral head position

It is also important to control the humeral head position. Specific drills are given to facilitate humeral head control. The most common aberrant position of the humeral head is an increase in anterior placement of the humeral head. A useful strategy to help facilitate co-contraction of the rotator cuff to help stabilize and centralize the humeral head is to facilitate a mid level isometric contraction of the rotator cuff by applying resistance to the humeral head (Dark et al., 2007).
Further on in the treatment this may be integrated into movement patterns. First in slow controlled concentric/eccentric motion drills, later isolated muscle strengthening drills.

Serratus anterior recruitment and control

Abduction external rotation strategies described above are often sufficient to trigger serratus anterior recruitment and control without the risk of over-activating pectoral minor muscle.