advanced cervical spine ii .web viewthe brachial plexus and the subclavian artery pass posterior

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Thoracic outlet syndrome3

Muscle energy techniques6


First rib14


Soft tissue mobilizations, ANTT, FMP20




Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a collection of signs and symptoms caused by compression and/or irritation of the brachial plexus and subclavian vessels.

Functional anatomy

Although patients with TOS present with a variety of signs and symptoms caused by compression/irritation of neurovascular structures, less than 5% of the cases are reported with true ischemia or atrophy. Knowledge of the functional anatomy of these neurovascular structures is an important factor in understanding this syndrome.

The upper and middle trunks of the brachial plexus slant downward from the neck. The lower trunk follows a different direction. The C8 nerve root, after it exits from the intervertebral foramen, runs almost horizontally before it is joined by the T1 nerve root to form the lower trunk of the plexus. The T1 nerve root runs cranial and somewhat anterior upon exiting the intervertebral foramen. The brachial plexus and the subclavian artery pass posterior to the anterior scalenus and anterior to the medial scalenus. The lower trunk of the plexus then crosses the first rib to enter the supraclavicular fossa, in close contact with the subclavian artery and vein, which pass under the subclavius muscle. The subclavian artery runs anterior/inferior to the lower trunk of the plexus. Cadaver dissections demonstrate that this lower trunk, while crossing the first rib, is frequently under considerable tension. The neurovascular bundle then passes below the pectoralis minor, near the insertion on the coracoid process. The C8-T1 nerve roots are most often involved in TOS.

TOS often occurs together with other nerve root compression syndromes. When single axons are compressed in one region (resulting in impaired neural function), they become especially susceptible to damage at another site. It is suggested that proximal compression of a nerve lessens its ability to withstand distal compression. This is also described as double crush phenomenon. Compression of a peripheral nerve decreases its intra neural circulation.

The internal fluid of the nerve is called axoplasm. The axoplasm is rather viscous, five times more viscid than water. The axoplasmic flow is the transport system that maintains a chemical connection between cell body, axon, nerve terminals and target cells. Axoplasm is thixotropic. This means that movement is necessary to keep viscosity low and prevent gelling. Axoplasmic flow varies. At times it can be up to 400 mm per day. At times it is slow, no more than 30 mm per day and is easily altered by compression or blood depletion. Flow alteration is dependent on duration and magnitude of compression. Once the flow is diminished for 8 hours or so, the nerve becomes sick and a chain response of problems begins to occur rather like a domino effect. Decrease of axoplasmic flow at one site predisposes the nerve at the other sites to injury; hence the phenomenon of double and multiple crush syndromes.

Patient profile

Female, late teens to 4th decade

Sedentary job with static use of UEs, repetitive use of the hands


Cause of TOS

Traumafracture of first rib, clavicle

Congenitalcervical rib

abnormal first rib

large C7 transverse process

Posture problemsforward head

depressed/downwardly rotated scapulae

protracted shoulders

Structures that can cause thoracic outlet syndrome

Scalenus anterior and medius

Cervical rib Elevated first rib Costoclavicular space

Pectoralis minor

Anterior capsule laxity of the glenohumeral joint


Usually vague, ill defined and defy categorization. Documentation in the literature of objective signs is rare. Symptoms may include upper quadrant pain, paresthesiae, numbness, weakness, coldness, swelling, discoloration, migraines, memory loss and ear pain. Most complaints of paresthesiae occur in the ulnar nerve distribution.

Vascular symptoms: whole arm numbness, weakness (heavy), cold, blanching, ischemic pain, and decreased radial pulse.

Neurological symptoms: segmental numbness, myotomal weakness, pins/needles (release phenomena), and pain.


Rounded shoulders, forward head, accessory breathing


Cervical ROM can be mildly limited, most problems occur with rotation/sidebending away. There will be upper thoracic and cervicothoracic restrictions.

Tension signs

Positive adverse neural tissue tension in UE.


Motor and sensation C4-T2 intact. Symmetrical UE DTRs

Muscle length

Short pectoralis minor

Special testing

Adsons test

Patient rotates head to side of symptoms, tuck chin and extend head slightly, externally rotate and extend arm. Take radial pulse. Patient inhales and holds breath for 10 seconds. Positive test: reproduction of symptoms and radial pulse disappears. Implicates scalenes.

Costoclavicular assessment

Externally rotate and extend the arm, draw the patients arm down and back. Palpate radial pulse. Patient inhales and holds breath for 10 seconds. Positive test: reproduction of symptoms and radial pulse disappears. This test is particularly effective in patients who complain of symptoms while wearing a backpack or a heavy coat.

Pectoralis minor

Retract patients shoulder. Take radial pulse. Have patient exhale and hold for 10 seconds. Positive test: reproduction of symptoms and radial pulse disappears.

Anterior capsule

Flex arm to 90 degrees, then horizontally abduct the arm so that the glenohumeral head glides anterior. Take radial pulse, hold 15 seconds.

Roos test

Patient put arms in stick up position and slowly flex/extend the fingers for 3 minutes. Positive test: arm feels heavy, patient complains of ischemic pain, paresthesiae or reproduction of other symptoms. Minor fatigue and distress are considered to be a negative response.

Evaluation of every structure from which symptoms arise is important. Often there are multiple sites of entrapment. The diagnosis is really a garbage can term. Treat what you find.


First rib mobilization

Address cervical and thoracic joint dysfunctions

STM, stretching to scalenes, pectoralis minor

Treat ANTT

Address postural dysfunction

Muscle Energy Techniques

O-A side gliding technique

To correct ESR lesion.

Patient supine. Sideglide patients head to the right, up to barrier. Use indirect action, so resist left sidegliding. Hold 6 seconds, 2-3 times. Retest.

Combined movement technique O-A

To correct ESR lesion.

Patient supine. Therapist at head of table. Hold occiput with left hand. Right hand controls the chin. Forearm against right side of the head. Flex head at O-A, sidebend left. If chin remains in midline, right rotation is automatic and can be neglected. Resist extension. Hold 6 seconds, then relocalize by flexing, sidebending left. Repeat 2-3 times. Retest.


For right rotation restriction.

Patient supine. Sidebend head to the left, rotate right into restriction. Resist left rotation of the head (indirect action). Hold 6 seconds, and then pick up slack in right rotation. Repeat 2-3 times. Do not lose left sidebending. Retest.


For left rotation restriction.

Patient supine. Fully flex the head and rotate left into restriction. Resist right rotation (indirect action). Hold 6 seconds, then pick up slack in left rotation. Repeat 2-3 times. Retest.

Mid cervical sidegliding technique

For restriction in right side gliding.

Side glide segment up to barrier. Have patient push head to the right, hold 6 seconds. Upon relaxation, pick up slack to reach barrier in right sidegliding. Repeat 2-3 times. Retest.

Combined movement technique

For restriction of flexion, left rotation and left sidebending (ERSR)

Patient sitting. Flex, sidebend left, rotate left up to barrier. Resist right sidebending or extension, hold 6 seconds. Upon relaxation, pick up slack to new barrier in flexion, sidebending and rotation. Repeat 2-3 times. Retest.

Cervicothoracic (C7-T3)

For restriction in extension, left sidebend, left rotation (FRSR).

In this technique the upper and mid cervical segments should not be extended. This can be achieved by having the patient tucking the chin. Another option is to use the therapists forearm to protect the neck.

Patient seated. Therapist behind patient. Left hand is placed over upper trap with thumb on the TP of affected segment. Right hand and forearm control the head. Extend to barrier. It helps to add some forward pressure with the thumb. By pushing with the left thumb in the direction of the opposite hip, you introduce sidegliding right to give sidebending left, up to barrier. Rotate left. Resist right sidebend or flexion, hold for 6 seconds. Pick up slack in all 3 directions to new barrier. Repeat 3 times. Retest.

Cervicothoracic junction


Typically this is not an area the patient points to for pain and/or dysfunction. However this is a key area for cervical mechanics. Usually the CT junction tends to be hypomobile, which contributes to cervical hypermobility.


Look for increased CT kyphosis (dowagers hump).