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Physical Therapy Management

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Conservative management should be the first strategy to treat TOS since this seems to be effective at decreasing symptoms, facilitating return to work and improving function, but yet a few studies have evaluated the optimal exercise program as well as the difference between conservative management and no treatment. Conservative management includes physical therapy, which focuses mainly on patient education, pain control, range of motion, nerve gliding techniques, strengthening and stretching.

Stage 1:

The aim of the initial stage is to decrease the patient’s symptoms. This may be achieved by patient education, in which TOS, bad postures, the prognosis and the importance of therapy compliance are explained. Furthermore, some patients who sleep with the arms in an overhead, abducted position should get some information about their sleeping posture to avoid waking up at night. These patients should sleep on their uninvolved side or supine, potentially by pinning down the sleeves. The Cyriax release test may be used if a ‘release phenomenon’ is present. This technique completely unloads the neurovascular structures in the thoracic outlet before going to bed.

Cyriax Release Maneuver

  • Elbows flexed to 90°

  • Towels create a passive shoulder girdle elevation

  • Supported spine and the head in neutral

  • The position is held until peripheral symptoms are produced. The patient is encouraged to allow symptoms to occur as long as can be tolerated for up to 30 minutes, observing for a symptom decrescendo as time passes.

The patient’s breathing techniques need to be evaluated as the scalenus and other accessory muscles often compensate to elevate the ribcage during inspiration. Encouraging diaphragmatic breathing will lessen the workload on already overused or tight scalenus and can possibly reduce symptoms.

Scapula Settings and Control

In the treatment, you first have to start with scapula settings and control.

This is important to establishing normal scapula muscle recruitment and control in the resting position. Once this is achieved then the program is progressed to maintaining scapula control while both motion and load are applied. The program begins in lower ranges of abduction and is gradually progressed further up into abduction and flexion range until muscles are being retrained in functional movement patterns at higher ranges of elevation.

Control the Humeral Head Position

It is also important to control the humeral head position. Specific drills are given to facilitate humeral head control. The most common aberrant position of the humeral head is an increase in anterior placement of the humeral head. A useful strategy to help facilitate co-contraction of the rotator cuff to help stabilize and centralize the humeral head is to facilitate a mid-level isometric contraction of the rotator cuff by applying resistance to the humeral head (Dark et al., 2007).

Further on in the treatment, this may be integrated into movement patterns. First in slow controlled concentric/eccentric motion drills, later isolated muscle strengthening drills.

Serratus Anterior Recruitment and Control

Abduction external rotation strategies described above are often sufficient to trigger serratus anterior recruitment and control without the risk of over-activating pectoral minor muscle

Stage 2:

Once the patient has control over his/her symptoms, the patient can move to this stage of treatment. The goal of this stage is to directly address the tissues that create structural limitations of motion and compression. How this should be done is one of the most discussed topics of this pathology. Some examples of methods that are used in the literature are.

  • Massage

  • Strengthening of the levator scapulae, sternocleidomastoid and upper trapezius (This group of muscles open the thoracic outlet by raising the shoulder girdle and opening the costoclavicular space)

  • Stretching of the pectoralis, lower trapezius and scalene muscles (These muscles close the thoracic outlet)

  • Postural correction exercises

  • Relaxation of shortened muscles 

  • Aerobic exercises in a daily home exercise program:

Exercises

  1. Shoulder exercises to restore the range of motion and so provide more space for the neurovascular structures.
    Exercise: Lift your shoulders backwards and up, flex your upper thoracic spine and move the shoulders forward and down. Then straighten the back and repeat 5 to 10 times.

  2. ROM of the upper cervical spine
    Exercise: Lower your chin 5 to 10 times against your chest, while you are standing with the back of your head against a wall. The effectiveness of this exercise can be enlarged by pressing the head down by hands.

  3. Activation of the scalene muscles is the most important exercises. These exercises help to normalize the function of the thoracic aperture as well as all the malfunctions of the first rib. Exercises are Anterior scalene (Press your forehead 5 times against the palm of your hand for a duration of 5 seconds, without creating any movement), Middle scalene (Press your head sidewards against your palm), Posterior scalene (Press your head backwards against your palm

  4. Stretching exercises

Other Interventions

  • Repositioning/mobilization of the shoulder girdle and pelvis joints: cervicothoracic, sternoclavicular, acromioclavicular, and costotransverse joints 

  • Glenohumeral mobilizations in end-range elevation with the elbow supported in extension

  • Taping: some patients with severe symptoms respond to additional taping, adhesive bandages or braces that elevate or retract the shoulder girdle.

Manipulative Treatment to Mobilize the First Rib

These should be carried out with caution and only after a thorough assessment as they can provoke irritation and pain symptoms in some patients

  1. Posterior Glenohumeral Glide with Arm Flexion:
    The patient is supine. The mobilization hand contacts the proximal humerus avoiding corocoid process. The force is directed posterolaterally (direction of thumb).

  2. Anterior Glenohumeral Glide with Arm Scaption:
    The patient is prone. The mobilization hand contacts the proximal humerus avoiding acromion process. The force is directed anteromedially.

  3. Inferior Glenohumeral Glide:
    The patient is prone. The stabilizing hand holds the proximal humerus, the humerus distal to the lateral acromion process. The mobilization hand contacts the axillary border of the scapula. Mobilize the scapula in a craniomedial direction along the rib cage.

Post-Op Physical Therapy

If a patient does require surgery, then physical therapy should follow immediately to prevent scar tissue and return the patient to full function.

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