So for TOS, or for thoracic outlet syndrome, vascular thoracic outlet syndrome is sort of one of the classic things that we used to think about, and that we used to always talk about, and that we used to always sort of approach and treat. So a vascular thoracic outlet is these vessels are emerging underneath the clavicle, between the clavicle and the first rib. They also have associations with the anterior middle scalene. Most of the time when you have vascular thoracic outlet, the symptoms are in the hand, not the shoulder. And patients have this renewed type of symptoms, so this quadrication in their hands. An angiogram or an MRI will show some narrowing of the actual vessels, especially if you do the provocative angiograms. And this test, the Adson test, has been thought to reduce the radial pulse when you extend the arm to the defective side, basically compressing the clavicle against the vessels and the first rib, and inhaling deeply, trying to sort of compress those vessels and see if you feel a reduced radial pulse. I'm going to talk about neurogenic thoracic outlet, though, because really neurogenic thoracic outlet is the most common. Many studies have suggested 95 to 98% of patients who have thoracic outlet actually have neurogenic thoracic outlet. I think that number is probably even higher as we're learning more and more about this pathology. So you can either have compression within the interscaling triangle, it's a little bit less common, or more commonly, below the pectoralis minor. So most of these patients will have anterior shoulder tightness. They'll feel like their shoulder is kind of, or their scapula is kind of protracted around. Many will have scapular dyskinesia. Many also will have radiating pain and parathesis. Now, not all of them have radiating pain and parathesis, but many of them do. Usually, it's associated with repetitive overuse, particularly overhead athletes. The most common I've seen are softball players, volleyball players, basketball players, gymnasts. It's repetitive overuse of overloading or loading their front part of their chest. You know, weightlifters also have a big issue with this. And the examination, and I'll go through this in a little bit more detail, but often the scapula won't move perfectly normally. They'll have tenderness either in their scalene or at the medial to the coracoid, right near the pectoralis minor insertion. And often, they'll have a positive supercapillary stretch test, and I'll show you what that is in a second. So, these are the different described examination maneuvers that have been classically described in the vascular surgery literature. So, the adsense test, as I mentioned, for neurodegenerative thoracic outlet, and you extend it to the affected side. You inhale deeply, and you see if you have pain radiating down the arm. The ruse test is where you externally rotate an abduct, you pump the hand for three or four minutes, and then you see if the patient has worsening symptoms or rapid fatigue. The right test is where you externally rotate and abduct the arm to 180 degrees. You inhale deeply, and you see if you have radiating or worsening pain. But these all have high false positives. And if I can be frank, I actually don't really use them that much. I do look at them, but I don't consider them as the make or break in this diagnosis. This is an example of some of the examinations I like to use. So, tenels in the interscaling triangle, tenels at the coracoid, or just medial to coracoid, this is kind of the arm extension and stretch test for both pectoralsis minor and suprascapular nerve. This is the suprascapular nerve stretch test, where you're kind of stretching the arm back. And then obviously looking at the scapula. And this is looking at the scapula, and you can see it's a little bit subtle, but she has this dyskinetic pattern where her scapula is not rotating properly, and it prevents her from lifting her arm up all the way. There's multiple other measurements that you can do. So, the pectoralsis minor index is where you measure from the coracoid to the fourth rib, basically measuring the length of the pectoralsis minor, and you divide it by the patient's height, and you multiply it by 100. This is a way, if you do it contralaterally, if you have sort of a 10 to 20% decrease, that's thought to be associated with the pectoralsis minor tightness or pectoralsis minor syndrome. You have scapula protraction height, the medial scapula angle, and the medial scapula height, all these different measurements that you can use to kind of help confirm that one side is different than the other, the scapula is not moving the same, and you have these sort of abnormalities within the scapula that you can sort of try to quantify. To diagnose it, really, you can look at a brachial plexus MRI, and we do get those. EMGs are important, and sometimes with POS, you'll actually see, not necessarily the classic antebrachial cutaneous nerve that people describe, but actually more commonly, you'll see suprascapular neuropathy that presents in these patients. So the suprasthenitis and amphithanitis have some innervation problems. And then diagnostic injections are without question the mainstay to both diagnose and at least start treatment on this. So these diagnostic injections, you can see here, this is provided by my partner, Robbie Bowers. Nirajanthi and Kim Mounter also contribute, but as you can see, Robbie's able to demonstrate the pectoralsis minor with the vessels and the nerves surrounding the vessels underneath it. You can see as you move over to the coracoid, once again, you can see the vessels and the nerves kind of underneath it. And this video kind of really nicely shows the pectoralsis minor going right over the top of the brachial plexus with these nerves, and obviously, they're actually already just underneath it. So it kind of shows why it could be compressed and why this often can be an issue. And this also is a nice dynamic video where you can kind of see moving from abduction to abduction, how you can have compression of these nerves, particularly against the ribcage, particularly if that pectoralsis minor is a little bit overactive. So how do I diagnose neurogenic thoracic outlet? Well, tennels or tinnitus palpation at the medial to the pectoralsis minor, a positive stretch test, so bringing the arm behind and kind of stretching the pectoralsis minor against the chest wall, scapular dyskinesia or some sort of abnormalities within the scapula, a positive response to ultrasound guided injections within the pectoralsis minor and or the suprascapular notch, and a negative vascular angiography, and an EMG workup that maybe will localize to the suprascapular nerve, but really won't show any signs of super cervical radiculopathy or anything else that shows of compressive neuropathy. When you refer patients to therapy, this unilateral corner stretch is one of my favorites. It really stretches out the pectoralsis minor, stretches out that anterior chest. You also want to do some scapular strengthening, postural correction. Remember, when you do these things, deltoid and rotator cuff strengthening actually can make it worse. It actually contracts the anterior chest down potentially more. It won't necessarily help. This is really more of a scapular and kind of chest wall phenomenon. Really important to focus on the scapula. Really important to retrain that scapular humoral rhythm. Coordinating the scapula and the humerus to basically work together and kind of move together without that kind of bumping disconnect pattern. There's multiple different therapies that you can think about. The scapular retraction, sleeper stretch, seated push-ups, butterfly. These are some of the ones I think are really helpful and really useful. There's many other ones that you can consider, but they're all about stretching and strengthening your scapula, your scapular humoral rhythm, and kind of this coordinated retraining of how these patients move their shoulders. I really like TLSL patients don't actually really like that much, but I actually really like these figure of eight braces. So this is what we traditionally used to use for clavicle fractures, but you can get these figure of eight braces very cheaply off the internet or at most brace shops, and it kind of really helps to hold the scapula back, hold the patient's posture, and really kind of improve their scapular humoral mechanics. One quick note. So scapular winging or scapular dyskinesia are not necessarily automatically neurogenic thoracic outlet syndrome. So I know I was talking about this idea of scapular winging a lot, but I want to sort of mention this, that as you can see in these two circumstances, a serratus anterior or long thoracic palsy, you can see in this young lady, her scapula is basically paralyzed. It's no longer able to be protracted against the chest wall, and you can see kind of how it pops out, and she was very, very limited in how much she can use it. The trapezius paralysis or spinal accessory paralysis, you can see he lost all of his external rotation of his scapula. So he's unable to lift his arm because he lost his external rotation. Instead, the scapula just rotates around the body and no longer does he have the scapula external rotation. So you think about this as lateral and medial, but it's really a loss of retraction against the body and a loss of lateral or a loss of external rotation of the trapezius. You can treat both these with a pectorals minor transfer, sorry, pectorals major transfer or the triple transfer. And just really quickly, I know this is a little bit outside the topic of this, but this is an example of scapular winging different from scapular dyskinesia. So this is a patient, 18-year-old with scapular winging, shoulder pain for about a year and a half. She had a fall during cheerleading. She was in significant pain, significant winging, and had failed extensive shoulder scapular therapy. She was even being considered for a labral repair, but naturally this wasn't really her main cause and ultimately did not undergo that surgery. Her shoulder spectra was 10% and she really, really was quite limited with this. And you'll see on this video how limited she was. So her trapezius and rhomboids were intact, but she really was not able to lift her arm because her scapula sort of lost that retraction against the chest wall. She had normal chondrology and she did not have any signs of Ehlers-Danlos syndrome or any other hyperlaxity. But you can see here she has this scapula that's protruding out and is unable to sort of stay against the chest wall because her serratus anterior is not working very well. You can see here I'm testing the strength of her serratus anterior by having her push against it. You can see on the other side she's very strong, but on this side she has basically no strength. And this is a really uncomfortable test for patients, but this is me holding the scapula reduced against the chest wall. You can see I can completely correct her ability to elevate her arm. Basically I'm doing the function of the serratus anterior. You can see in these images they're basically normal x-rays, normal images, although you can see why one of the surgeons thought she potentially had some posterior labral instability. Her brachial plexus MRI was basically normal, but her EMG did show some long thoracic rhythms. And so you have this patient who has a long thoracic denervation, no open injury, but likely a bulge or stretch trauma. So what do you do for this patient? Well, she had been referred to a sports psychologist. She's been referred to a variety of other people as sort of a variety of other surgeons to bounce around for a bit. But ultimately we did decide to actually treat this with a, after an interoperative EMG showed that there was no stimulation. I'll just show this quick animation. So we did this sternal head of the pectoralis major transfer. So you take off the clavicular head, you then pass the sternal head of the pectoralis major back basically right next to the chest wall. And you can kind of imagine how it mimics the serratus anterior.

2nd Edition, CASE 49

2nd Edition

Shoulder

neurogenic thoracic outlet syndrome

scapular dyskinesia

diagnostic techniques

therapeutic exercises

pectoralis major transfer