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   Dr. Deborah Denno
        NMS 670

   • AKA: Neurovascular Compression
• Classic Presentation: Diffuse arm
  symptoms, numbness, tingling;
  typically down medial arm to 4th and
  5th digits.
• Symptoms are worse with overhead

• Generalized Symptoms: Pain in the
  upper extremity, paraesthesia,
  numbness, weakness, skin
  discolorations, swelling, Raynaud’s
          Anatomy of TOS
• The Neurovascular Bundle (NVB):
  – Brachial Plexus
  – Subclavian Artery/Vein
  – Axillary Artery/Vein
                Causes of TOS
•   Elongated C7 TVP
•   Cervical Rib (or fibrous band)
•   Trauma, exostosis
•   Posture induced (Forward head/rounded shoulders)
•   Pancoast Tumor
•   Scalene Muscles (spastic, flaccid, or anomalous)
•   Costoclavicular area
•   Subcoracoid area (Pec minor/Coracoid Pr.)
             Cervical Ribs
• A congenital overdevelopment, bony or
  fibrous, of the C7 costal process. Can be
  unilateral or bilateral
• Usually asymptomatic.
• Occurs in 1% of the population and only
  10% of those are symptomatic.
• Pain and paresthesias in the medial forearm
  and hand, usually relieved by changing
  position. Can have weakness and difficulty
  with fine motor control.
          Interscalene Triangle
•   Anterior Scalene
•   Middle Scalene
•   T1 Rib
•   Subclavian Artery
•   Brachial Plexus

• Subclavian Vein passes anterior
Interscalene Triangle
   Scalenus Anticus Syndrome
• Scalene muscles elevate the 1st Rib, lateral
  flexion and rotation. Also flexion.
• C8/T1 are at greatest risk.
• Symptoms: pain, paresthesia, hyperesthesia
  and numbness. These can occur anywhere
  from the shoulder to the fingers.
• Ischemia: numbness, cold, weakness, and
  skin color changes.
• Adson’s Test is diagnostic
    Costoclavicular Syndrome
• NVB is compressed between the 1st Rib,
  Subclavius muscle and Clavicle.
• The Subclavian Vein is most susceptible.
  – Sense of Fullness in the Hand and Fingers
  – Cramping pain in the forearm and hand
  – Vague shoulder pain
  – Swollen and engorged veins-intermittent
  – Symptoms don’t follow dermatome or NR.
  Shoulder ROM is maintained.
  Costoclavicular Maneuver and Eden’s Test are
    Hyperabduction Syndrome
• Occurs with repetitive or prolonged
  hyperabduction of the arm.
• Involves the BP and Axillary Art/Vein
• Compressed by tendon during Abduction.
• Pain, paresthesia, and numbness occur first
  in the fingers, later in the hand.
• May resemble Raynaud’s Ds.
• Neurologic symptoms are usually absent.
• Wright’s Test is diagnostic
              General Rules
• Symptoms depends on:
  – Frequency
  – Duration
  – Degree of Compression

  Perform Allen’s Test first to determine the
    patency of the Radial and Ulnar Arteries.
            Treatment of TOS
•   Postural Correction
•   Stretching tight muscles
•   Strengthening weakened muscles
•   Trigger Point Therapy
•   Adjust the 1st Rib
•   Adjust clavicle, shoulder, C and T spines
             Special Studies
• X-ray for fracture/dislocation, cervical ribs
• Arteriography for patency of vessels.
         Differential Diagnosis
•   Central Lesions Spinal Cord Tumors
•   Plexus Lesions Pancoast tumor
•   Peripheral Nerve Lesions
•   Carpal Tunnel Syndrome
•   Cardiac Symptoms

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