The Clinical Coach: Pseudo-Thoracic Outlet Syndrome

Happy Friday!

I sure hope you’ve had an amazing week, and I hope you are about to enjoy a great weekend!

For the time being I am holding off on our Tuesday’s PRO10 segment and I’ll be spending more time writing The Clinical Coach (clinical education) & The Performance Doctor (business education).

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This week we are talking about that nasty second removed, nobody likes to talk about, cousin of Thoracic Outlet Syndrome. Yes.

Pseudo Thoracic Outlet Syndrome

Let’s get to it…

What is…. pseudo thoracic outlet syndrome?

I wish I could tell you it was made up, but isn’t everything made up?

P-TOS is when a patient presents with the symptoms of thoracic outlet syndrome without compression of the structures that are causing the symptoms.

Exactly. It gets confusing.

One moment you think you have a TOS patient, and then during your examination nothing comes up positive!

Why does it matter?

P-TOS can be confused not only with it’s cousin TOS, but it can also be confused with a brachioplexopathy, a cervical radiculopathy, carpal tunnel syndrome and even cubital tunnel syndrome.

Therefore a thorough examination of the cervical spine and the upper extremity is warranted.

Not because it’s dangerous, but because you don’t want to miss something else.

Most common MOI

Just like Thoracic Outlet Syndrome, P-TOS can present after whiplash, sports injuries, falls, or repetitive motions (swimmers) and even in athletes who repeatedly throw over head (baseball players).

Signs, Symptoms and Clinical Presentation

Patients presenting with P-TOS may present with:

• numbness of the upper extremity

• tingling of the upper extremity

• shoulder pain

• neck pain

• arm fatigue with activity

You can see how this clearly looks like TOS right? Unlike TOS, the symptoms don’t typically worsen with neck or arm positioning.

Examination + Diagnostic Tools

But unlike TOS, P-TOS does not seem to always reproduce the symptoms in office when orthopedics like Roos or EAST are performed. As a matter of fact most patients that present with P-TOS are able to complete Roos 90% of the time.

This should clearly give you an idea that the neural compression presented is not a true TOS presentation.

Palpation of the following muscles is warranted:

• pec major/minor

• scalenes

• trapezius

• supraspinatus/infraspinatus

A good cluster to perform and rule out a radiculopathy would be the cluster of Wainner. Which encompasses:

• Upper Limb Tension Test (supine)

• Cervical Rotation (seated or supine)

• Cervical Distraction (supine)

• Spurling’s (the right way)

3/4 of these test positive then you have a radiculopathy in your hands.

Imaging

X-ray is helpful in the diagnosis of TOS if you are suspecting the patient’s symptoms may be from a first rib.

In P-TOS, there is no true compression of the neural structures. Therefore X-ray would only be warranted if you suspect your patient might have a hidden fracture based on their history.

Another test that could be helpful in patients with persistent numbness and tingling to the fingers would be a nerve conduction study. Helping you localize where the nerve has been injured.

Treatment

By now you should have a very good idea of the which muscles, structures and tissues need treatment.

Conservative Care

If this was my patient, I’d dry needle the tight/tender tissues and muscles.

Introduce my patient to nerve glides, mostly median nerve glide adjust the thoracic and cervical spine.

Finally introduce them to the door frame stretch, and Bruegger’s stretch.

Once they start seeing some reduction in symptoms then we’d start a more dedicated strength and conditioning program for them.

Non-Conservative Care

It’s no surprise that there’s a non-conservative approach. The most common one is going to be a corticosteroid injection, followed by a nerve block.

This is not something I would recommend unless your patient has had ZERO improvements in a 6 week trial of care.

At this point, you might’ve missed something.

Clinical Pearls

If symptoms are not reproduced with nerve compression tests like Roos, or EAST. Then you are most likely not dealing with TOS.

If your patients symptoms worsen or they hands turn purple as they elevate the arms, you ARE dealing with TOS.

Conclusion

Do you think you could diagnose TOS vs P-TOS?

It took me a few times to finally get the hang of it, but it should take you significantly less with this information.

How you choose to treat these tissues and which movements to focus, will depend on your patient’s goals, wants and needs as well as your experience developing a program that will meet them where they are and will progress them accordingly.

Until our next issue!

In health and strength,

If you are ready to level up your skills here’s how I can help:

1. Join over 250+ Certified Dry Needling Practitioners and enroll in our upcoming Certified Dry Needling Practitioner cohorts.

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