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The examination by a physiotherapist often begins before the patient has started to remove their clothes by assessing the patient\’s posture. Slumped or rounded shoulders and a protracted neck posture put the shoulder blade and neck muscles on a stretch and may contribute to bringing on symptoms. Neck active movements will be tested and the physio will make note of any loss of motion. The physio may place the neck in a combined stressful position involving downward forces to see if this will elicit symptoms, with shoulder range of movement also recorded.

The examination will include the ability of the nervous and vascular system to supply the requirements of the arm, with most of the deficiencies involving the lower nerves of the brachial plexus. Compression of the veins in the armpit area results in an arm which is bluish in colour and swollen, whilst if the part of the vascular system which is compressed is an artery this makes the arm cooler, lacking in a pulse and often having a lower blood pressure of 20 mmHg or more compared to the normal arm.

In the case of thoracic outlet syndrome due to neurological compression the finding are often of weakness and wasting of the small muscles of the hand. There may also be reduced sensation in the areas supplied by the ulnar nerve, which again reflects the fact that the lower nerves of the brachial plexus are most often involved. The last type of this syndrome, that of non-specific thoracic outlet syndrome, has widespread but less precisely located pain, with less precise and clear examination findings, making the diagnosis unreliable at best.

The large number and type of anatomical structures potentially contributing to thoracic outlet syndrome has meant that there is a large number of tests to provoke the symptoms of the typical syndrome. Unfortunately these tests result in high numbers of results which are false-negative and false positive. False-negative results mean that the tests did not show any evidence for the syndrome but it is present anyhow, and false-positives mean that the test shows the presence of the syndrome when in reality it is not present.

A typical test is Roos stress test, where the patient keeps their arms up in a \”hands up\” position, opening and closing the fist. If the symptoms come on or the arms feel heavy or tired then the test may be taken to have a positive result. The reasons for thoracic outlet syndrome can either be due to bony structures or soft tissue structures. Bony structures which might cause compression or obstruction include cervical ribs and bony outgrowths on the ribs or collar bone. Soft tissue structures involved include abnormal fibrous bands or abnormally large muscles in weight training athletes.

Trauma to the neck and mechanical stressors may combine with any abnormalities in neck anatomy such as cervical ribs to increase the likelihood of developing thoracic outlet syndrome. Obstruction of the blood supply is an emergency and should be speedily assessed and surgically decompressed with repair to the arteries or veins. Most people with this syndrome are however treated conservatively with anti-inflammatory drugs, transcutaneous electrical nerve stimulation (TENS) and assessment and mobilisation or exercise prescription by a physiotherapist.

Surgical management continues to be an option in patients whose pain does not settle but the mainstay of treatment remains conservative measures. Physiotherapy review takes in any abnormal muscle balance around the area and any postural abnormality in the thorax, shoulders and neck. If one posture is held for long periods or repeatedly returned to then this may cause dysfunction of neck structures.

An increase in the local compressive or tension forces can be produced by postural abnormality, causing the nerves to suffer chronic compression. Keeping of muscles in a shortened posture changes their normal length, makes them weaker and means they react with pain when stretched. Muscles can also become lengthened and weakened by being chronically stretched, and along with shortened muscles this forms the idea of muscle imbalance producing symptoms. The longer term changes in posture which are required to make an improvement in this syndrome mean that patient education is a priority.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, Physiotherapists in Bournemouth, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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