C L IN IC A L C A SE REPO RT
®2016 Human Kinetics - IJATT 21(5), pp. 14-20
http://dx.d0i.0rg/l 0,1123/ijatt.2015-0080
Neurologic Thoracic Outlet Syndrome:
A Case Report and Clinical Review
Gregory G. Billy • Penn State Sports Medicine; Sayers J. Miller • The Pennsylvania State
University
An avid weightlifter presented with complaints of right arm and hand numbness. His workup was consistent
with neurologic thoracic outlet syndrome with severe conduction block at the level of the supraclavicular
fossa. He chose conservative treatment, which focused on correction of thoracic and cervical segmental
dysfunction, upper crossed syndrome muscle imbalances, and upper trunk and anterior forward head pos­
tural concerns. Upon completion of the therapy program and continuation of a home exercise program,
his conduction block and symptoms resolved. Conservative treatment may be an effective alternative to
surgery for neurologic thoracic outlet syndrome. Key Words: conservative treatment, physical therapy,
postural corrections
he term thoracic outlet syndrome (TOS)
was first described by Peet et al. in 1956.'
Since that time, there has been great
debate as to the etiology and classification
of the syndrome. It is generally accepted
that TOS is the name given to several disorders
attributed to compromise of various neurovascular
structures between the base of the neck and the
axilla.2The symptoms can involve the upper extremity
nerves or vessels depending upon the etiology of the
compression. Treatment has historically been surgical
decompression for vascular, neurologic, or mixed TOS.
Clinical Scenario
A 55-year-old male presented to a physiatrist with a
two-year history of left shoulder pain. He is an avid
weightlifter. He reported a feeling of “restricted circula­
tion” of the left shoulder and neck area and described
intermittent left hand stiffness with associated numb­
ness throughout the entire arm. He initially noticed
his symptoms while doing the bench press. His symp­
toms exacerbated shortly after he was diagnosed with
14 I SEPTEMBER 2016
gastroesophageal reflux disease (GERD) and began
sleeping on his stomach with his arms in an abducted
and externally rotated position. His physical examina­
tion was significant for mild atrophy of the abductor
pollicis brevis (APB) muscle. He had normal bilateral
upper extremity motor and sensory examinations. He
had a drop in his left radial pulse from a 2 + to a 1 +
with abduction and external rotation of the shoulder.
His physiatrist performed an electrodiagnostic study
(see Table 1 for results). Findings were significant for
conduction blocks at the supraclavicular fossa of the
median nerve of 83 % and the ulnar nerve of 89 %.
Median and ulnar sensory findings were normal. Electro­
myography examination revealed reduced interference
pattern without any denervation of either the abductor
pollicis brevis or first dorsal interosseous muscles.
He was referred to a vascular surgeon for evaluation
and possible decompression surgery and underwent
additional testing. A chest radiograph was obtained
to evaluate the presence of a cervical rib or enlarged
transverse process and the study was negative for the
presence of either. He also underwent arterial pho­
toplethysmography and venous duplex testing, which
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
Ta b l e 1
m otor
C o n d u c t io n S t u d ie s
Seq.
Amplitude Amplitude Distance Velocity Temperature
(cm)
(mV)
(% )
(°()
(m/s)
Rec.
Site
Lat.
(ms)
Wrist
APB
3.8 5
11.4
100
8
Elbow
APB
8.0 5
11.6
102
22
Nerve/Sites
L M e d ia n —APB July 2 0 1 4
30 .2
5 2 .4
30 .2
Axilla
APB
12.10
10.6
91.7
22
54.3
30 .2
Supraclavicular fossa
APB
17.80
0.9
8.74
19
33.3
30 .2
Wrist
APB
3 .5 0
11.7
100
8
Elbow
APB
7.40
11.7
100
22
56 .4
31.7
Axilla
APB
11.10
11.5
98.3
22
59 .5
31.7
71.7
31.7
L M e d ia n — APB F ebruary
2015
31.6
APB
13.75
11.6
100
19
Wrist
ADM
4.0 5
9.6
100
8
B. Elbow
ADM
8.3 5
7.3
7 6.5
23
52.3
30 .2
30 .3
Supraclavicular fossa
L U ln ar— ADM July 2 0 1 4
30.3
A. Elbow
ADM
10.85
6.5
8 9.4
8
4 4 .4
Axilla
ADM
8 .1 5
6.2
94.3
16
59.3
30.3
Supraclavicular fossa
ADM
15.65
0.4
5.89
19
25.3
30.3
Wrist
ADM
3.6 5
11.8
100
8
B. Elbow
ADM
8.1 5
10.4
8 7 .6
23
51.1
31.2
A. Elbow
ADM
10.45
9.8
9 4 .5
8
47.1
31.8
Axilla
ADM
12.80
10.3
105
16
68.1
31
L U ln ar—ADM F eb ru ary 2 0 1 5
31.4
107
19
Supraclavicular fossa
ADM
15.30
11.0
7 6.0
31
Abbreviations: Rec. = recording; Lat. = latency; Seq. = sequential;; L = left; APB = abductor pollicis brevis; ADM = adductor digiti minimi; B. =
below; A. = above.
Note. This table shows the results of the nerve conduction studies and conduction blocks of the median and ulnar nerves. It also shows the fol­
low-up study results with noted resolution of the blocks.
did not show any obstruction of flow in either the neu­
tral or abducted positions of the shoulders in either the
arterial or venous vessels. He deferred decompression
surgery and wanted to proceed conservatively with
physical therapy.
Physical therapy was initiated, with the patient
attending a total of nine sessions over a 12-week
period. Each treatment session consisted of 30 min
of manual therapy followed by approximately 30
min of exercise. The program involved forward head
posture correction education; mid to upper thoracic,
cervicothoracic junction, upper rib, and lower to mid
cervical mobilization/manipulation; cervical retrac­
tion range of motion exercises; myofascial release;
stretching of scalene and pectoralis minor muscles;
and strengthening of the lower trapezius and serraINTERNATIONAL JOURNAL OF ATHLETIC THERAPY &. TRAINING
tus anterior. Mobilization/manipulation procedures
used during the course of treatment are illustrated
in Figure 1.The treatment plan addressed findings of
thoracic and cervical segmental dysfunction, scalene
and pectoralis minor hypertonus/tightness, adverse
upper limb neural tension, upper crossed syndrome
muscle imbalances, anteriorly tilted scapulae, and
forward head posture. His specific treatment plan is
described in Table 2. The focus of the treatment plan
was to address the spinal segmental causes of muscle
hypertonus and neural irritation, improve posture and
scapular position, and establish a home exercise pro­
gram for self-care. Exercises were added or progressed
based in part on the patient’s progress, symptoms, and
motivation. Representative exercises are illustrated in
Figure 2 and the home exercise program is outlined
SEPTEMBER 2016 I 15
Figure 1 Manual therapy techniques. The accompanying figures show the specific manual therapy techniques used. (A) Cervicothoracic junction
side bending manipulation. (B) Cervical rotation mobilization/manipulation. (C) Midthoracic rotational PA mobilization/manipulation. (D) Mid to
upper thoracic AP manipulation.
Ta b l e 2
Session
l
P h y s ic a l T h e r a p y T r e a t m e n t P l a n
Treatments
Initial ev a lu a tio n . P o stu re a n d b o d y m e c h a n ic in stru c tio n . Mid to u p p e r th o rac ic, c e rv ic o th o ra c ic ju n c tio n ,
u p p e r rib, a n d low er to m id cervical m o b iliz a tio n /m a n ip u la tio n . In stru c te d in cerv ical re tra c tio n activ e ra n g e of
m o tio n ex ercises.
2
C o n tin u ed w ith above. A dded low er tra p e z iu s a n d sc a p u la r p ro tra c tio n (all 4s p o sitio n w ith o p p o site a rm a n d
leg e x te n d e d ) exercise. A dded p re ssu re re le a se a n d stre tc h in g to sc a le n e s a n d p ec to ralis m inor. In stru c te d in
a n te rio r c h e st stretch in g .
3
S a m e as se ssio n 2.
4
C o n tin u e d w ith ab o v e w ith th e a d d itio n of w all a n g e ls (ch allen g es th o ra c ic e x te n sio n , a n te rio r c h e s t flexibility,
sh o u ld e r e x te rn a l ro tatio n m ob ility a n d p ro v id ed low er tra p e z iu s stre n g th e n in g ) a n d s c a p u la r sta b ility m o to r
co n tro l ex e rc ise (p a tie n t s ta n d s facing w all, p re ssin g ball a g a in st wall w ith sc a p u la p ro tra c te d , th e n p e rfo rm in g
CW a n d CCW m o v e m e n ts w hile m a in ta in in g sc a p u la r po sitio n ).
5
S a m e m o b iliza tio n a n d s tre tc h in g /re le a se p ro c e d u re s a n d ex e rcise s. A dded sc a p u la r p ro tra c tio n w ith h a n d on
BOSU in all 4s p o sitio n w ith s a m e sid e leg e x te n d e d a n d 35-lb d u m b b e ll in o p p o site h a n d . Also a d d e d w all
p u s h u p s w ith a plus a n d s c a p tio n ex e rc ise w ith a 5-lb w eig h t.
6
S a m e as se ssio n 5.
7
A dded sta n d in g sh o u ld e r e x te rn a l ro ta tio n w ith d u m b b e ll in sid e b e n t p o sitio n a n d sta n d in g D2 PNF p a tte rn
w ith m ini lunge. T he p a tie n t a d d e d T-bar row s at h o m e .
8
C o n tin u e d w ith m a n u a l th e ra p y a n d ex ercises. A ddition of s h o u ld e r e x te rn a l ro ta tio n w ith pulley, lo w er tra p e ­
zius “Y” e x e rc ise w ith pulley, a n d D2 PNF w ith lunge.
9
C o n tin u e d w ith m a n u a l therap y . A dded sc a p u la r stab ilizatio n w ith B ody Blade, d y n a m ic p ra y e r stre tc h (ch ild ’s
po se) w ith s c a p u la r p ro tra c tio n , a n d sta n d in g sh o u ld e r slid es (sh o u ld er flexion w ith sc a p u la r p ro tra c tio n e x e r­
cise to facilitate s c a p u la r control).
Abbreviations: CW = chest wall; CCW = contralateral chest wall; PNF = proprioceptive neuromuscular facilitation.
Note.
This table outlines the emphasis of each physical therapy session.
16 I SEPTEMBER 2016
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY 5 l TRAINING
Figure Z
Demonstration of the home exercise program. The series of figures highlight some of the exercises of the home exercise program. (A)
Anterior chest elevation with cervical retraction and upper cervical flexion. (B) Cervical retraction. (C) Scapular protraction. (D) Wall angels. (E)
Lower trapezius strength exercise.
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY St TRAINING
SEPTEMBER 2016 I 17
Ta b l e 3
Emphasis
Postural advice
Active range of motion
Strengthening
Stretching
N o te .
H o m e E x e r c is e P r o g r a m
Exercise
Anterior chest elevation with
cervical retraction and upper
cervical flexion
Cervical retraction
Lower trapezius retraction
Scapular protraction in all 4s
Shoulder flexion wall slides
Anterior chest stretching
Wall angels
Frequency
As much as possible throughout day
10 reps, 5-6 times daily
3 sets of 10 daily
3 sets of 10 daily
3 sets of 10 daily
3-5 30-s stretches, 2-3 x /day
3 sets of 10 daily
This table indicates the emphasis, exercise, and frequency of the patient’s home exercise program.
in Table 3. The patient remained adherent to a daily
exercise program and has not had any recurrence of
symptoms.
He returned for follow-up evaluation and noted
complete resolution of his symptoms and a follow
up electrodiagnostic study was performed (see Table
1 for results). Findings were significant for complete
resolution of his prior median and ulnar conduction
blocks at the supraclavicular fossa. Electromyography
examination also showed resolution of the reduced
interference pattern of the opponens pollicis and first
dorsal interosseous muscles.
Discussion
TOS may vary in its clinical presentation due to either
vascular and/or neurologic compression. A classifi­
cation proposed by Wilbourn defined vascular, neu­
rologic, and neurovascular types, and the neurologic
classification was further divided into true and non­
specific subtypes based upon specific electrodiagnostic
findings.3
Nonspecific TOS represents the majority of TOS
cases, upwards of 85 %.4’5 Vascular TOS includes
approximately 5-10% of all TOS cases.6 Vascular TOS
can be further subdivided into arterial TOS or venous
TOS. Vascular TOS typically involves compression of
the subclavian and/or axillary vessels.
Nonspecific cases of TOS usually dem onstrate
no bony or soft tissue abnormality. The potential site
of entrapment is beneath the tendon of the pectoralis minor muscle where the plexus is vulnerable
to stretching by shoulder abduction.7' 9 The patient’s
symptoms were first noted with the bench press,
18 I SEPTEMBER 2016
which places the shoulders in an abducted position,
and were later exacerbated with sleeping prone with
abducted shoulders. Intermittent compression of the
neurovascular complex is felt to be due to repetitive
postural, occupational, or sporting forces that create
temporary compression at varying sites.10 Our patient
responded to a specific protocol to improve tightness
and compression at the scalene and pectoralis areas.
True neurologic TOS is very rare, with an esti­
mated incidence of one case per million or two cases
detected every year in an electrodiagnostic clinic out of
approximately every 2,000 patients.11 True neurologic
TOS occurs far more commonly in females who often
suffer from severe atrophy of the thenar muscles.12
Nerve conduction findings classically show an absent
or reduced medial antebrachial cutaneous sensory
nerve action potential (SNAP), reduced ulnar sensory
SNAP, and reduced median motor compound muscle
action potential (CMAP), while electromyography
findings revealed absent or reduced abductor pollicis
motor unit action potentials (MUAP).12' 15 Radiographic
abnormalities including cervical ribs and elongated C7
transverse processes are typically present, and patients
benefit from surgical decompression of an associated
fibrous band.
This clinical case is unique given the dramatic
electrodiagnostic findings at the time of presentation.
Other studies in the literature describe the benefits of
conservative treatment for TOS, although their diagno­
ses are based on clinical symptoms of the patient and
not objective measures.16-19 The electrodiagnostic study
shows both conduction block and median/ulnar nerve
conduction velocity drops of 25~33m/s across the site
of compression, which then normalized to 71 -76 m/s
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
following treatment. The findings normalized over a
10-12 week period, which is surprising given the sig­
nificance of the compression. Electrodiagnostic studies
have shown such prolonged interpeak and absolute
latencies with proximal stimulation to be significant.22
The improvements were clinically validated with the
resolution of the electrodiagnostic changes.
Given the clinical and electrodiagnostic findings,
a surgical approach was considered.20'21 The patient
did not exhibit signs of vascular compromise, but it
is important to remember when working patients up
for TOS, the neurogenic and vascular compromise
may frequently coexist.23 The patient underwent the
vascular studies to rule out a vascular component. In
addition, surgery may also be of benefit in patients
with electrodiagnostic findings of denervation, as it
has been shown that early decompression decreases
the occurrence of muscle wasting and denervation
of nerves compared with late surgery.24 Our patient
showed neither vascular compromise nor denervation.
The clinical response of the patient was noted over
a 12-week time period and is in agreement with an
advocated conservative approach of therapies for up
to three months.25 The dramatic resolution of both the
conduction block and clinical findings with the afore­
mentioned therapy principles suggest a conservative
option may be an appropriate treatment for patients
with nonspecific neurologic TOS, and the clinical utility
of serial electrodiagnostic studies. This case highlights
effective interprofessional and interdisciplinary patient
care between the patient’s physiatrist, vascular con­
sultant, and physical therapist. Given the complexity
of TOS, coordinated effort fosters the likelihood of a
successful outcome.
Lastly, this case illustrates a conservative approach
to significant neurologic thoracic outlet syndrome with
conduction block caused by postural problems, tight
and imbalanced muscles, and related cervical and
thoracic joint dysfunction in a weightlifter. He was
able to avoid surgery with a physical therapy program
that addressed these concerns via postural education,
manual therapy, and exercise. Conservative treatment
may be an effective alternative to surgery for neuro­
logic TOS.
C lin ic a l B o tto m Lino
The literature can be conflicting in recommending sur­
gery or conservative care. This case presented is unique
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY &. TRAINING
given the improvements in clinical findings were
confirmed by resolution of objective electrodiagnostic
findings in TOS. We strongly support the conservative
approach outlined in the report for nonspecific TOS. I
References
1. Peet RM, Henriksen MD, Anderson TP, Martin GM. Thoracic outlet
syndrome: evaluation of a therapeutic exercise program. Proc Staff
Meet May Clin. 1956;31:281-287. PubMed
2. Gilliatt RW. Thoracic outlet syndromes. In: Dyck PJ, Thomas PK, Lam­
bert EH, Bunge R, eds. Peripheral neuropathy. 2nd ed. Philadelphia:
WB Saunders; 1984:1409.
3. Wilbourn AJ. Thoracic outlet syndrome, in: Syllabus, Course D:
Controversies in entrapment neuropathies. Rochester, MN: American
Association of Electromyography and Electrodiagnosis; 1984:28.
4. Sanders RJ, Annest SJ. Technique of supraclavicular decompression for
neurogenic thoracic outlet syndrome.,/ Vase Surg. 2015;61 (3):821 -825
doi: 10.1016/j.jvs.2014.11.047. PubMed
5. Povlsen B, Hansson T, Povlsen SD. Treatment for thoracic outlet
syndrome. Cochrane Database Syst Rev. 2014;11:CD007218. PubMed
6. Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. Conservative
treatment of thoracic outlet syndrome. A review of the literature. Eura
Medicophys. 2007;43(l):55-70 Epub 2006 Sep 24. PubMed
7. Ranney D. Thoracic outlet: an anatomical redefinition that makes
clinical sense. Clin A m t. 1996;9(1):50—52. PubMed doi: 10.1002/
(SICI) 1098-2353(1996)9:1 < 50::A1D-CA10 > 3.0.CO;2-9
8. Rayan GM. Thoracic outlet syndrom e. J Shoulder Elbow Surg.
1998;7(4):440-451. PubMed doi: 10.1016/S1058-2746(98)90042-8
9. Demondion X, Bacqueville E, Paul C, Duquesony B, Hachulla E, Cotten
A. Thoracic outlet: assessment with MR imaging in asymptomatic
and symptomatic populations. Radiology. 2003;227(2):461 -468 Epub
2003 Mar 13. PubMed doi: 10.1148/radiol.2272012111
10. Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 1:
clinical manifestations, differentiation and treatment pathways. Man
Ther. 2009;14(6):586-595 doi:10.101 6/j.math.2009.08.007 Epub
2009 Sep9. PubMed
11. Gilliatt RW. Thoracic outlet syndromes. In: Dyck PJ, Thomas PK, Lam­
bert EH, Bunge R, eds. Peripheral Neuropathy. Philadelphia: Saunders;
1984:1409-1424.
12. Le Forestier N, Moulonguet A, Maisonobe T, LegerJM, Bouche P. True
neurogenic thoracic outlet syndrome: electrophysiological diagnosis in
six cases. Muscle Nerve. 1998;21 (9): 1129—1134. PubMed doi: 10.1002/
(SICI) 1097-4598(199809)21:9 < 1129::A1D-MUS3 > 3.0.CO;2-9
13. Kothari MJ, Macintosh K, Heistand M, Logigian EL. Medial antebrachial
cutaneous sensory studies in the evaluation of neurogenic thoracic outlet
syndrome. Muscle Nerve. 1998:21 (5):647-649. PubMed doi: 10.1002/
(SICI) 1097-4598(199805)21:5 < 647::A1D-MUS13 > 3.0.CO;2-S
14. Machanic BI, Sanders RJ. Medial antebrachial cutaneous nerve mea­
surements to diagnosis neurogenic thoracic outlet syndrome. Ann Vase
Surg. 2008;22(2):248-254 doi:10.1016/j.avsg.2007.09.009. PubMed
15. Tsao BE, Ferrante MA, Wilbourn AJ, Shields RW. Electrodiagnostic
features of true neurogenic thoracic outlet syndrome. Muscle Nerve.
2014;49(5):724—727 doi:10.1002/mus.24066. PubMed
16. Walsh MT. Therapist m anagem ent of thoracic outlet syndrome.
J Hand Ther. 1994;7(2): 131-1 44. PubMed doi: 10.101 6/S08941130(12)80083-4
17. Bilancini S, Lucci M, Tucci S, Di Rita L. Postural physiotherapy: a
possible conservative treatm ent of the thoracic outlet syndrome.
Angiologia. 1992;44(2):67-72. PubMed
18. Novak CB, Collins ED, Mackinnon SE. Outcome following conser­
vative management of thoracic outlet syndrome. J Hand Surg Am.
1995;20(4):542-548. PubMed doi:10.1016/S0363-5023(05)80264-3
SEPTEMBER 2016 I 19
19. Lindgren KA. Conservative treatm ent of thoracic outlet syndrom e:
a 2-year follow-up. Arch Phys Med Rehabil. 1997;78(4):373-378.
PubMed doi: 10.1016/S0003-9993(97)90228-8
20. Landry GJ, Moneta GL, Taylor LM, Jr, Edwards JM, Porter JM. Long-term
functional outcom e of neurogenic thoracic outlet syndrom e in surgi­
cally and conservatively treated p a tie n ts ./VaseSurg. 2001 ;33(2):312 319. PubMed doi: 10.1067/m va.2001.112950
21. Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R, FreischlagJA.
Surgical intervention for thoracic outlet syndrom e improves p atient’s
quality of life./ Vase Surg. 2009;49(3):630-635; discussion 635-637.
22. Papathanasiou E, Zam ba E, Papacostas S. Normative values for high
voltage electrical stimulation across the brachial plexus. Electromyogr
Clin Neurophysiol. 2002;42(3): 151-157. PubMed
23. Likes K, Rochlin DH, Call D, FreischlagJA. Coexistence of arterial com­
pression in patients with neurogenic thoracic outlet syndrome. JAMA
Surg. 2014; 149(12): 1240-1243 doi: 10.1001 /jamasurg.2014.280. PubMed
20 I SEPTEMBER 2016
24. Al-Hashel JY, El Shorbgy AA, Ahmed SF, Elshereef RR. Early versus
late surgical treatm en t for neurogenic thoracic outlet syndrom e.
1SRN Neurol. 2013 Sep 10:2013:673020. doi:10.1155/2013/673020.
eCollection 2013.
25. Lee J, Laker S, Fredericson M. Thoracic outlet syndrom e. PM R.
2010;2(l):64-70. PubMed doi:10.1016/j.pmrj.2009.12.001
Gregory G. Billy is w ith th e D e p a rtm e n t of O rth o p aed ics a n d R eha­
bilitation, Penn State Sports M edicine, State College, PA.
Sayers J. M iller is w ith th e D e p a rtm e n t of Kinesiology, The Pennsyl­
vania State University, U niversity Park, PA.
Trent Nessler, PT, DPT, MPT, C ham pion Sports M edicine/Physiotherapy
A ssociates, is th e re p o rt e ditor for this article.
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