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not undergo permanent morphological change. The nerve conduction tests will therefore remain within normal parameters. To avoid mis-diagnosis and inadequate treatment TOS should not be immediately ruled out of the diagnostic equation if the investigations are found to be negative (25). All facets for establishing the diagnosis must be taken into consideration. A thorough examination of the cervical spine and upper limb is required (5). The history, aggravating factors, easing factors, site and nature of the symptoms as well as elimination of other potential structures is used to determine the hypothesis against which treatment is performed. Differential diagnosis includes: n cervical spine radiculopathy (5,13) n ulnar neuropathy (cubital tunnel syndrome or compression at Guyon’s canal) (5) n carpal tunnel syndrome (5) n sub-acromial impingement n rotator cuff lesions n frozen shoulder (13) n tumours of the apex of the lung or other adjacent tumours (27) n ‘dead arm syndrome’ which can
occur in patients with multidirectional instability of the gleno-humeral joint (28) n compression of the brachial plexus can also occur if there is anterior displacement of the head of humerus n trigger points of the supraspinatus, scalenes, infraspinatus and pectorals can also mimic the pain of TOS (13). If arterial compromise is suspected the differential diagnosis must include: n arteriosclerosis (30) n and vascular arteritis which includes a heterogenous group of conditions. Referral to a vascular consultant for
further investigation and final diagnosis of any suspected vascular compromise must be actioned.
TREATMENT
The principles of treatment are: n Relief of compression of the neurovascular bundle n Relief of traction of the neurovascular bundle n Restoration of the normal intraneural anatomy and physiology which involves resolution of intraneural oedema, restoration of intraneural circulation, restoration of intraneural and extraneural gliding.
Figure 8: Langers arch
ESTABLISHED BASED ON A BALANCE OF EVIDENCE FROM THE MEDICAL HISTORY, CLINICAL EXAMINATION AND INVESTIGATIONS
Manual practitioners may
THORACIC OUTLET SYNDROME: ASSESSMENT, DIFFERENTIAL DIAGNOSIS AND HANDS-ON TREATMENT
1 day course with Teri Bayford 15th
19th 12th 16th
May 2010 Manchester June 2010 Sept 2010
London (TBC)
October 2010 Bristol Please see www.physiouk.co.uk for details and to book.
PRICE: £112.50 (if booked before early bird deadline – see website for deadlines)
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commence treatment for neurogenic TOS immediately following assessment and diagnosis. The timing for commencing treatment is essential. Early treatment can lead to a successful outcome. Chronic compromise of neural structures may lead to intraneural scarring (26) which creates enormous difficulties in the treatment of this syndrome. Manual treatment that is analysed as being useful in reducing compromise of a vascular structure should only commence following assessment and further investigation by a vascular consultant or an orthopaedic consultant with a special interest in TOS. Presence of a thrombus must be ruled out as must the need for arterial repair. Liaison with the vascular or orthopaedic consultant should be performed before treatment of subjects with vascular compromise begins if the manual treatment is indicated.
SUMMARY There are three variations of TOS: n aenous n arterial n neurogenic
sportEX medicine 2009;44(Apr):13-17
THE FINAL DIAGNOSIS NEEDS TO BE
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