Thoracic Outlet Syndrome in Athletes

[Justin Pretlow]

Hello All –
I had an eval Thursday of a 21 year old about 2 months status/post 1st rib resection, anterior and middle scalene resection for vascular(venous) and neurogenic TOS, per the op report.

Attached is an article I found helpful despite it’s lack of detail regarding physical therapy interventions.
I’ve had very little experience working with patients who have TOS or have undergone surgical intervention for TOS. This paper gave me a starting point for considering prognosis, return to sport, duration of treatment, and longterm recovery following surgery.
My patient was a high school wrestler, so not a high level athlete currently. His main goal is to regain full use of his shoulder and return to lifting weights at the gym without any recurring symptoms. Of the young athletes in the study, 80-90% were back to their sport(in some capacity) in 4.5 months. This gives me some idea of a realistic time frame for my patient to return to exercising and lifting. The main focus of the article is the surgical care/outcomes, so the details about PT were vague – strength and ROM for the first 6-8 weeks post surgery.
However, this article led me down the rabbit hole to another by the same authors, outlining their considerations/algorithm for surgical candidates. I will attach this article as well. Progress with conservative physical therapy(quick Dash outcome measure) and self-motivated home exercises were used as criteria to choose candidates likely to benefit from surgery for TOS. This article briefly references TOS-specific PT, which is described as interventions that mimic relaxation of the thoracic outlet. (A protocol is referenced by Edgelow,P.I. including breathing, relaxation, posture and positioning – I couldn’t access the link; working on finding it elsewhere).

Can anyone share their thoughts on exercise interventions for neurogenic TOS symptoms that seemed to work very well, or not at all?
If you do have an idea to share, can you also offer the rationale/anatomical considerations for how that intervention impacted the structures related to the symptoms?

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[Aaron Hartstein]

Hi Justin,
TOS can be a frustrating thing to work with, especially considering the lack of great evidence to guide our assessment and treatment, as well as the poor special tests we have to identify these issues. We will talk about this some in Weekend 3, but the majority of these cases are considered disputed neurogenic TOS (90+%) and have (-) diagnostic testing. True vascular, arterial, or neurogenic, only accounts for < 10% of these cases – and they will have (+) testing/imaging. Successful treatment of these folks is really an exercise in anatomy and understanding where the inferior portion the plexus can be restricted, what adjacent structures could promote this dysfunction (thoracic spine, CT junction, 1st/2nd rib, posterior capsule of shoulder, pec, AC/SC joint, etc), and having procedures to assess this – ULPT 3, for example. I would recommend approaching this the same as you approach other patients – identify objective impairments, have solid objective *, treat an area, and reassess that area, as well as others to determine what type of carry over you have, if any. Here is a nice series that Phil Sizer put out a couple of years about that has a helpful table about how to structure treatment pending their response to our objective testing. Hope this helps.
Aaron

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[Justin Pretlow]

Thanks Aaron,
That’s definitely helpful. Eric gave me a couple of articles to solidify my understanding of the anatomy. The treatment suggestions in part 2 above look really helpful at a glance.

To the residents- If anyone has access to the article url below, could you forward me the pdf? Thanks

http://www.mskscienceandpractice.com/article/S1356-689X(10)00038-X/fulltext

[Aaron Hartstein]

Here you go.
Aaron

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[Kyle Feldman]

Hey Justin

I treated a baseball pitcher who was post op about 1.5 years ago. He ended up going back to throwing so I would say it was pretty successful.

We started mainly with manual along the scalnes, thoracic container and along the Ulnar nerve pathway.

Exercise was focused on primarily lower trap, lat, and cuff strengthening.
Pain and symptoms reproduction was the limiting factor.

Once we progressed with shoulder stabilization and weight bearing we began the throwing return.

I used the Drew Brees return to throwing article by Reinold and Wilk

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