Patients with thoracic outlet syndrome (TOS) may have undiagnosed pain and symptoms into their shoulder, arm, hand, scapula, head, face, upper back, axilla, chest and anterior clavicle.

With a number of potential sources of pain in these areas, TOS patients commonly have a delayed or incorrect diagnosis, followed by unnecessary and unsuccessful surgery. Further complicating matters, imaging and nerve conduction studies are often clear or inconclusive. Studies show that on average, patients with TOS have an average of 5 years of symptoms and see 6 doctors before receiving an accurate diagnosis.

What tests and questionnaires will help guide your diagnosis and intervention? When are patients suitable for Physiotherapy and conservative management? When should you refer on for a surgical opinion?

In this podcast with Jo Gibson (Clinical Physiotherapy Specialist), you will discover:

• What is Thoracic outlet syndrome (TOS)?
• Commonly reported symptoms of TOS
• Three different types of TOS
• The most common type of TOS with around 80% of all TOS patients
• Why imaging and investigations are often clear, and don’t match up with symptoms
• 3 key causes of TOS
• The relationship between TOS and hypermobility syndrome
• Criteria for diagnosis in the latest TOS diagnostic consensus statement
• Differential diagnosis (DDx) - Cervical NR compression, and peripheral nerve entrapment
• Common subjective findings that guide you towards a diagnosis of TOS
• A questionnaire you can use to assist cervicobrachial diagnosis
• What information is gained from imaging, including MRI and MR Neurography & nerve conduction studies
• What are the limitations of imaging?
• What is the difference between small nerve fibre and large nerve fibres, and how this impacts diagnosis
• QST - Quantitative sensory testing - Pin prick (Neurotip) and Thermal testing - warm and cold
• Simple QST test using a coin
• Objective testing
  • What tests do you need to perform in patients with suspected TOS?
  • What is the elevated stress test (EST)?
  • What information does an upper limb tension test (ULTT) provide?
  • Does a negative ULTT test exclude TOS?
• How are nerve blocks used?
• What is the best way to perform a nerve block?
• How effective are nerve blocks in assisting diagnosis?
• Who should we refer on for early medical or surgical management?
• When should you get an early surgical opinion?
• Which patients are likely to benefit from conservative management?

Podcast handout

Free shoulder assessment infographic series

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Shoulder: Steps to Success online course with Jo Gibson

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Links associated with this episode:

• Get your access to the free video series “Frozen shoulder assessment & treatment” with Jo Gibson
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• Infographics by Clinical Edge
• Jo Gibson on Twitter
• Thoracic outlet syndrome centre of excellence

Articles associated with this episode:

• Download the podcast handout to receive the articles associated with this podcast.

• Illig KA, Donahue D, Duncan A, Freischlag J, Gelabert H, Johansen K, Jordan S, Sanders R, Thompson R. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. Journal of vascular surgery. 2016 Sep 1;64(3):e23-35.

• Jordan SE, Ahn SS, Gelabert HA. Differentiation of thoracic outlet syndrome from treatment-resistant cervical brachial pain syndromes: development and utilization of a questionnaire, clinical examination and ultrasound evaluation. Pain Physician. 2007 May;10(3):441-52.

• Kenny RA, Traynor GB, Withington D, Keegan DJ. Thoracic outlet syndrome: a useful exercise treatment option. American journal of surgery. 1993 Feb 1;165:282-.

• Ridehalgh C, Sandy-Hindmarch OP, Schmid AB. Validity of clinical small–fiber sensory testing to detect small–nerve fiber degeneration. journal of orthopaedic & sports physical therapy. 2018 Oct;48(10):767-74.

• Zhu GC, Böttger K, Slater H, Cook C, Farrell SF, Hailey L, Tampin B, Schmid AB. Concurrent validity of a low‐cost and time‐efficient clinical sensory test battery to evaluate somatosensory dysfunction. European Journal of Pain. 2019 Nov;23(10):1826-38.