Thoracic Outlet Syndrome: Understanding Unusual Clinical Presentations

Thoracic Outlet Syndrome

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Thoracic outlet syndrome (TOS) is an often poorly understood condition. It’s so poorly understood, in fact, that some even question its existence!

A 2014 Cochrane review begins with the statement, “Thoracic outlet syndrome is one of the most controversial diagnoses in clinical medicine.”1 Because of the lack of objective findings, the diagnosis is often made through reviewing the patient’s history and subjective complaints combined with a physical examination.2

Primary complaints of TOS typically include numbness, paresthesias, and/or weakness in the arm, hand, or digits.3 A retrospective analysis of prospectively collected data on 118 patients found the following symptoms to be most predictive of neurogenic TOS4:

  • Pain at the base of the neck
  • Upper extremity paresthesias
  • Symptom exacerbation by arm elevation
  • Tenderness at the scalene triangle or pect minor
  • Positive Roos (Elevated Arm Stress Test) within three minutes

I have been treating disputed neurogenic TOS patients for the past 20 years with the majority of patients presenting with the symptoms described above.

But what about when they don’t present with “typical” symptoms? I would like to share with you two specific clinical cases in which the underlying issue turned out to be TOS; however, very little matched with the clinical criteria.

Case 1: Hannah, a 20-Year-Old Music Major

“Hannah” is a 20-year-old right-hand-dominant female music major who presented with cramping of the left hand into a claw position at the ring and small fingers. This cramping occurred when she played the piano for less than 10 minutes.

Hannah had no complaints of neck, shoulder, or upper extremity pain and no complaints of paresthesias. Her symptoms began three months ago and had gotten progressively worse. She was concerned that she would not be able to play the piano and meet the requirements of her music curriculum.

Hannah had seen a neurologist, and she’d had an EMG of her ulnar nerve done, which was negative. She was also being worked up for complex regional pain syndrome (CRPS) due to her occasional complaints of ”burning” in the ulnar aspect of her hand. When referring Hannah to hand therapy, the physician indicated that the therapy was for “strengthening for ulnar intrinsic strain.”

While performing the Roos/elevated arm stress test, Hannah’s left ring and small fingers cramped into a claw position within eight seconds, reproducing her complaints. Further clinical testing revealed that her left first rib was elevated and her scapula mildly depressed, contributing to downward traction on the ulnar nerve, resulting in distal cramping. Hannah’s left grip was 24 pounds with mild pain at the ulnar aspect of her hand and 52 pounds on the uninvolved right.

Hannah’s treatment focused on restoring her first rib mobility with joint mobilization techniques, improving her resting scapular alignment with scapular taping using McConnell tape, ulnar nerve flossing, and restoring her upper thoracic mobility along with scapular stabilizer strengthening.

Within three weeks, Hannah’s cramping symptoms had completely resolved, and she demonstrated a twenty-pound improvement in her grip strength. She was thrilled!

You can learn more about the techniques discussed here in my MedBridge courses:

Case 2: Jessica, a 31-Year-Old Art Teacher

“Jessica” was one of the most difficult cases I have ever encountered. She was a 31-year-old female art teacher with a history of progressive onset of “pressure and pain” in her neck with any type of forward bending or lying in a supine position. She also had some left upper extremity paresthesias, which worsened with overhead motion.

I first met Jessica approximately eight weeks after she had undergone a left first rib resection and scalenectomy, performed with the transaxillary approach. She noted that her left upper extremity symptoms had resolved, but nothing had changed with her neck symptoms. While lying in an inclined position, she presented with progressive jugular vein distention (see video below) to the point Jessica reported, “I feel like my head’s going to blow off.” To get any kind of relief, Jessica was sleeping in a completely upright position.

I began Jessica’s treatment with soft issue techniques to her rectus abdominus and along the infrasternal angle, as she presented with very little rib cage mobility. At the time, she noted that “everything feels stuck.”

The more ventral trunk mobility we gained, the more her symptoms began to lessen, to the point that she was able to once again sleep in an inclined position. Her insurance plan fortunately allowed for multiple visits, and over the course of months, she was able to sleep at a 70-degree angle, then 50, then 30, and then eventually in supine without experiencing the jugular vein distention.

Jessica was diligent with her home program to maintain the soft tissue mobility in her pects and ventral trunk. While she hasn’t needed therapy in three years, I just recently spoke with her again, and she reports that she is still doing well and keeping up with her home program! What surgery wasn’t able to change, we were able to change with therapy.

You can learn more about the treatments in this case in the recording of my recent live webinar, “Maximizing Neural Mobility in the Upper Extremity.”

The next time a patient comes to you with a more unusual clinical presentation, keep these cases in mind!

  1. Povlsen, B., Hansson, T., & Povlsen, S. D. (2014). Treatment for thoracic outlet syndrome. Cochrane Database of Systematic Reviews, 26(22), CD007218.
  2. Povlsen, S. & Povlsen, B. (2018). Diagnosing thoracic outlet syndrome: current approaches and future directions. Diagnostics, 8(1), 21.
  3. Weaver, M. L. & Lum, Y. W. (2017). New diagnostic and treatment modalities for neurogenic thoracic outlet syndrome. Diagnostics, 7(2), 28.
  4. Balderman, J., Holzem, K., Field, B. J., Bottros, M. M., Abuirqeba, A. A, Vemuri, C., & Thompson, R. W. (2017). Associations between clinical diagnostic criteria and pretreatment patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome. Journal of Vascular Surgery, 66(2), 533–544.e2.