Thoracic Outlet Syndrome (Neurogenic)

Case Study: Thoracic Outlet Syndrome (Neurogenic)

The purpose of this case study wass to assist one of our graduate Physiotherapists to fully reflect on a client that they
had seen throughout the week. This also forms part of information that we can distribute to clients where they can read up on real life cases where we have been able to and allow them to be pain free! 

Section 1: About your client and how you diagnosed the condition (think about how they presented, what subjective and objective information did you gather to help you diagnose?)

Client presented with long standing pins and needles down their arms and into both hands – in particular fingers 4 and 5 feeling completely numb following sleep. The client sleeps with arms above their head under the pillow. This in itself is placing more stretch onto a particular nerve that supplies your 4th and 5th digits
known as the ulnar nerve.
The client also expressed an increase in symptoms when strength training. Massage has previously relieved symptoms – particularly around the front of shoulder/ chest area. This is a common area of massage that does provide relief to this condition.
In terms of testing to confirm, testing of nerve lengths revealed more tension on the left side. Symptoms down the arm were also provoked with sustained pressure over both the pectoralis minor, and even more so over the scalenes muscles. These are muscles that these nerves as well as other vessels pass through.
The ROOS stress test is a test for TOS and is evaluated by how long it takes to provoke the clients symptoms.
In this case, symptoms were provoked within 45 seconds o the left side. Average onset for this test is 1 minute 42 seconds

Section 2: Your diagnosis and about the condition (what is your possible diagnosis?)

Possible diagnosis: Thoracic Outlet Syndrome (Neurogenic)

Pathophysiology background: Thoracic Outlet Syndrome is a group of disorders that occur when blood vessels or nerves are compressed
between your collarbone and first rib (space known as your thoracic outlet).

Symptoms include:

Pain in the shoulders and neck, numbness, weakness and coldness in the fingers.

Section 3: Differential Diagnosis (what is another condition to consider and why?)

Brachial plexus injury, cervical radiculopathy, peripheral nerve entrapment

Section 4: Treatment (what did you do and why?)

Began with some massage of the common areas of nerve compression. This included the anterior scalenes as well as the pectoralis minor. The result of this was great short term relief and a reduction in pins and needles over the following days, namely no pins and needles when waking up from sleeping.
This was then complimented with some strengthening exercises for the upper back and neck area to maintain the benefits of the massage as well as optimise the shoulders movement to prevent recompression of the nerves.
Finally, some nerve mobility exercises were given, particularly to the nerve that has caused pins and needles when waking up.

Section 5: Plan (where to go from here? How many sessions might they need? What’s the goal?)

Exercises will continue to optimise shoulder function and progress towards the client goals. In this clients case, strength training without provoking pins and needles – of which have hampered grip strength.
There will also be progressions in terms of the nerve stretches. The goal of this to reduce the sensitivity of the nerve, increase its mobility as well as its capacity to withstand consistent stretching and loading.


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