Outlet within an outlet
The term Thoracic Outlet Syndrome was used for the first time in the literature by Rob and Standeven. It had also been termed costoclavicular syndrome, cervical rib syndrome, scalenus anticus syndrome, subclavius tendon syndrome, or musculus pectoralis major syndrome by various authors.
The Thoracic outlet consists of three outlets, namely the superior thoracic outlet, the costoscalene hiatus and the costoclavicular passage.
The costo-clavicular passage is formed by the clavicle antero-laterally, the first rib medially, and the scapula posteriorly.
Neurovascular structures like the brachial nerve plexus, subclavian artery and subclavian vein run within the costoclavicular space between the first rib and the clavicle and are vulnerable to compression in this space.
The costoclavicular syndrome was first described in soldiers with loaded knapsacks, who developed pain, numbness, and fatigue of the arms as they stood at attention.
The compression of the neurovascular structures is caused by the downward movement of the clavicle against the first rib which reduces the space in the passage leading to shearing of the neurovascular bundle. This can happen because:
The clavicle depresses toward/against the first rib usually as in the common postural condition of rounding and slumping shoulders. This narrows the costoclavicular passage by pushing the scapula forward
A tight subclavius muscle or tight, narrow brassiere straps supporting heavy breasts exert direct downward pressure on the clavicles. As a result, there is a scissoring action of the clavicle against the first rib, causing the narrowing of the costoclavicular passage and shears the neurovascular bundle.
Elevation of the first rib towards the clavicle as in patient with laboured breathing. Tight anterior and middle scalene muscles and subclavius can also cause this to occur.
Depression of clavicle and elevation of first rib.
pain, paresthesia, and tiredness of the upper limbs are the main presenting complaints. It may be accompanied with pain and stiffness of neck and shoulders. Symptoms are exhibited bilaterally with discomfort on the dominant side.
They are aggravated by work and exercise, particularly carrying heavy shopping bags.
Symptoms are relieved by rest and sleep, are minimal or absent in the morning, and become pronounced as the day progresses.
Patients occasionally complain of puffy blue hands
Pain and tenderness in the acromioclavicular joint usually respond to local ice or heat and simple analgesics.
Elimination of the cause of symptoms like use of trolley bags instead of heavy shoulder bags and use of broad and padded straps or strapless brassiers.
Stretching for not just subclavius muscle, but the tissues of entire costoclavicular space must be considered. The tissues of the costoclavicular space should be stretched by passively bringing the client’s arm back into extension and up into abduction.
Also, any other muscles that can either elevate the first rib into the clavicle or depress the clavicle into the first rib should be worked. These include the scalene, pectoralis minor and pectoralis major.
Posture correction directed at avoiding stooping and shoulder girdle exercises can help a lot.
Occasionally an injection of corticosteroid and local anesthetic into the acromioclavicular joint may be required. In extreme cases surgical reduction of breast size by mammoplasty produces excellent results.
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