Bilateral Functional Thoracic Outlet Syndrome in a Collegiate Football Player

A TOS Case Study by Jason H. Robey and Kyndall L. Boyle using the Postural Restoration Institute's intervention method.
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  ABSTRACT  Background. Thoracic Outlet Syndrome (TOS) involvescompression of the brachial plexus, subclavius artery andvein. Many studies discuss efficacy of surgery and few dis-cuss conservative treatment. It is unknown what specificforms of conservative treatment are best. Objective. Describe conservative management for TOSusing unique exercises. Case Description. A collegiate football player reportednumbness/tingling down his right arm after a right brachial plexus stretch injury. Seven months later, he wasdiagnosed with recurrent cervical traction neuropraxia.Two months later, he reported bilateral symptoms and wasdiagnosed with functional TOS. The athlete began shoul-der strengthening (deltoid, middle trapezius, rhomboids,pectoralis major, latissimus dorsi, biceps, upper trapeziusand rotator cuff) and stretching (pectoralis, scalene andupper trapezius) which failed to resolve his symptomsafter four weeks. Surgical resection of bilateral first ribsand quitting football was recommended by four physi-cians. Unique therapeutic exercises developed by thePostural Restoration Institute™ were used to optimize res-piration/posture via muscle activation and inhibition.After six weeks, the athlete was asymptomatic andreturned to football but still experienced paresthesia withcontact. Additional exercises were prescribed and remain-ing symptoms were abolished. Outcomes. The Northwick Park Neck Pain Questionnairewas 55.5% at initial and 0% at four weeks and discharge.  Discussion. Athlete did not demonstrate relief of symp-toms from shoulder stretching and strengthening.Intervention designed to optimize respiration/posture byrepositioning the pelvis/trunk via specific muscle inhibi-tion and activation resulted in abolishing the athlete’ssymptoms. Management that aims to optimize respirationvia muscle inhibition, activation, and repositioning war-rants further research.  Key words: thoracic outlet syndrome, postural restora-tion, respiration CORRESPONDENCE Kyndall L. Boyle, PT, PhD, OCSProgram in Physical Therapy PO Box 15105Flagstaff, AZ 86011-5105e-mail: ACKNOWLEDGEMENTS We would like to thank the Postural Restoration Institute™for their creative development of the specific therapeuticexercises that were prescribed for the patient in this casereport. CASE REPORT Bilateral Functional Thoracic OutletSyndrome in a Collegiate Football Player Jason H. Robey, ATC a  Kyndall L. Boyle, PT, PhD, OCS  b a Appalachian State UniversityBoone, NC  b Northern Arizona UniversityFlagstaff, AZ North American Journal of Sports Physical Therapy | Volume 4, Number 4 | November 2009 |Page 170      N     A    J     S    P     T  INTRODUCTION Thoracic outlet syndrome (TOS), also known as neurovas-cular compression syndrome, consists of a group of dis-tinct disorders that affect the nerves or vascular structures between the base of the neck and axilla. 1,2 Specifically,these disorders result from positional compression of thesubclavian artery or vein, and the brachial plexus nervesin a variety of locations including the cervical spine (fromcervical rib), scalene interval, infraclavicular space orunder the pectoralis minor tendon. 3 The brachial plexus isdivided into an upper plexus (median nerve distribution)and a lower plexus (ulnar nerve distribution). 4 Upperplexus compression was initially described by Swank andSimeone4 with symptoms secondary to C5, C6, and C7nerve root compression. Sensory changes will primarilyoccur in the first three fingers, and associated muscleweakness or pain in the anterior chest, triceps, deltoids,and parascapular muscles, as well as down the outer fore-arm to the extensor muscles. 4 Lower plexus irritationinvolves C8 and T1 nerve root compression. Sensorychanges primarily occur in the fourth and fifth fingers,with muscle weakness or pain from the rhomboid and thescapular muscles to the posterior axilla, down the ulnardistribution of the forearm, involving the elbow, wrist flex-ors, and the intrinsic muscles of the hand. 4 Thoracic outlet syndrome disorders are complex, poorlydefined, and a diagnosis of exclusion that can cover a widerange of ailments each producing various signs and symp-toms arising from the upper extremity and the chest,neck, and head. 2,5,6 An accurate diagnosis of TOS requiresa thorough history and physical examination. Several testsexist that may be used to assist in diagnosing TOS, includ-ing nerve conduction velocity (NCV), electromyography(EMG), radiographs, computed tomography (CT) scan,and magnetic resonance imaging (MRI). 4 Authors haveattempted to study the thoracic outlet region by CT scanor MRI. One of the limitations is that the compromise of the neurovascular bundle is often positional and intermit-tent. 2 In neurogenic TOS, electrophysiological testing isoften entirely normal. EMG can sometimes detect neuro-genic C8/T1 signs. 2 Thoracic outlet syndrome can be a result of posturalalterations, hypertrophic muscles, muscle imbalances, anelevated first rib, presence of a cervical rib, and macrotrau-ma such as automobile accidents. 5 These syndromes have been categorized into anatomical and functional TOS. 5 Anatomical TOS includes congenital anomalies or trau-matic osseous and soft tissue injury. Functional TOSincludes postural adaptations as a result of work or sportparticipation, respiratory changes, and psychological con-ditions. The literature suggests that a variety of methods have been traditionally used to manage TOS. 2,5,7 Conservativeinterventions focus on pain control, 7,8 edema control, ver- bal posture education and ergonomics, 7,9-14 relaxation, 15 stretching, strengthening, and nerve gliding exercises. 7,16,17 Additional interventions include moist heat, 7,18,19 massage, 20 acupuncture, 20 cervical traction, manual joint mobiliza-tion, 21 first rib mobilization, 15,19  braces, 22 and aerobic exer-cises.9 Exercises to manage TOS may focus on stretchingthe levator scapulae, lower trapezius, scalenes, and pec-toralis muscles, 2,7,19,21 and strengthening the cervical exten-sors, scapular adductors, and shoulder retractor mus-cles. 2,7,19,21 Additionally, cervical traction, isometric exercis-es (cervical spine and shoulder girdle), and manual jointmobilization (cervical-thoracic spine, sternoclavicular joint, acromioclavicular joint and costothoracic joint) has been described in the literature. 21 Any of the described methods have been advocated toalter posture in some way. 2,5,7 Authors of a recent literaturereview for TOS conclude that although conservative treat-ment may reduce symptoms and improve function, it isnot known if this approach is significantly better than notreatment or placebo. 5 The most commonly recommend-ed interventions are strengthening and stretching of theshoulder girdle musculature. 2,7,19,21 However, little agree-ment exists on which muscles need strengthening andwhich ones need lengthening. 5 These types of exercises donot detail how they address functional TOS as a result of respiratory alterations and they do not aim to inhibit mus-cle. 1,5,19 Postural Restoration is a holistic posture based approach topatient management that considers the influence of dys-functional respiration on posture and utilizes therapeuticexercises that activate or inhibit specific muscles and man-ual trunk techniques as needed in order to achieve opti-mal respiration and posture. 23 Postural Restoration alsorecognizes patterns of postural asymmetries (similar toKendall’s 24 right handed pattern) that are believed to bepresent in most people to varying degrees. Clinicians whouse Postural Restoration, therefore, often target interven-tion to correct the asymmetrical pattern. 23,25 This patternis consistent with the pre-existent vertebral rotation in North American Journal of Sports Physical Therapy | Volume 4, Number 4 | November 2009 |Page 171  “normal” individuals. 26 The postural restoration methodol-ogy has been used to manage patients with sciatica andlow back pain, 27 asthma, 28 anterior knee pain, 29,30 andtrochanteric bursitis. 31 This approach has appeared to besuccessful in managing athletes with iliotibial band syn-drome, 32 and patients with chronic pain 33 and knee pain, 34 however, the evidence for these three conditions remainsanecdotal. To date, no case studies describing the use of Postural Restoration for a patient with TOS have been pub-lished. The purpose of this case is to describe manage-ment of a collegiate football player with bilateral function-al TOS who was first managed with traditional therapeuticexercises and then with unique Postural Restoration ther-apeutic exercises to address his faulty posture and subop-timal respiration. CASE DESCRIPTION The athlete was a 22-year-old male collegiate football play-er (tight end). Social history included living with threeother football players in an apartment with parents livingan hour away. Other than his current condition, his gen-eral health including physical, psychological, and socialfunction was excellent. Athlete denied use of alcohol,tobacco, or any drugs. He had an unremarkable medicaland family history. The chief complaint for this footballplayer included sustaining a right brachial plexus injuryduring the fall football season. Approximately sevenmonths later, the athlete suffered multiple brachial plexusinjuries to his right neck during spring football practice.Cervical spine radiographs were taken and he was seen bythe team orthopedic surgeon. Radiographs revealed mild-moderate posterior osteophyte formation at C6- C7 greaterthan C5- C6 with elevation of the ribs. The physician diag-nosed the athlete with cervical traction neurapraxia andprescribed Ibuprofen and Vicodin. Due to the athlete’s signs and symptoms progressively becoming worsened, he altered his posture to favor theinvolved side. This compensation in his posture potential-ly led to the left side becoming involved. He then begandeveloping radicular pain down his left arm and into hishand. Now his signs and symptoms consisted of bilateralnumbness, tingling, and weakness into his hands (mediannerve distribution), achy pain in shoulders, and a shootingsensation down both arms, pain at Erb’s point, 7 tendernessto palpation over anterior chest and neck muscles, andtenderness and pain between his right scapula and verte- bral column at the level of T4. These findings were con-sistent with someone who has sustained an upper plexuscompression injury. 35 Postural observation revealed bilateral: hypertrophic/over-developed latissimus dorsi, pectoralis, upper trapez-ius and bicep muscles, anterior rib flares (ribs are in aposition of external rotation/elevation which is a com- bined position of chest expansion with pump handle and bucket handle motions), 36 increased lumbar lordosis (over-active paraspinal muscles), left pelvic forward rotation,forward head posture, and over-active neck musculature.He reported that he was unable to sleep on either side andhad to sleep prone with his face buried in his hands. Theathlete had several positive tests including Adson’s, 37 Allen’s, Military Brace and Roos. 3,37-39 Two months later he was sent for a cervical spine MRI, a bilateral brachial plexus MRI, a nerve conduction velocitytest, and an EMG. The cervical spine MRI was normal.The bilateral brachial plexus MRI revealed muscularhypertrophy in the neck and shoulders. All other struc-tures appeared normal. The nerve conduction velocitytest and EMG studies revealed ulnar nerve compression atthe elbow on the right. The test results were negative onthe left. It was interesting to note that the athlete did nothave any neurological symptoms in the ulnar distributionof his hand. An orthopaedic surgeon diagnosed him with bilateral functional TOS. The physician recommendedthat he should discontinue playing football. Multiplephysicians advised him to consider having surgery forresection of both first ribs as a last resort. The athletedecided to take a conservative approach to see if he could benefit from non-surgical management. He was managed by three different clinicians over the course of care andseen daily in the athletic training room. See Table 1 fordosage of interventions. Intervention – Clinician 1 The first clinician focused on traditional recommendedinterventions, primarily guided by information on a web-site for TOS including stretching and strengthening exer-cises.19 Specific interventions (done twice a day, sevendays a week) consisted of: moist heat for fifteen minutes(over the neck and both shoulders in sitting to prepare forstretching), self stretching exercises (three repetitions x 30seconds) for bilateral neck, shoulder, and chest muscles(scalenes, upper trapezius, pectoralis major muscles), ver- bal postural education (to keep head and shoulders back,and chin and chest up) and shoulder strengthening using North American Journal of Sports Physical Therapy | Volume 4, Number 4 | November 2009 |Page 172  tubing for the rotator cuff (internal and external rotationmuscles), deltoid, pectoralis major, latissimus dorsi,supraspinatus, biceps, and upper trapezius muscles. Allstretches were performed three times for 30 seconds each,the exercises were done in three sets of fifteen each, andall treatment was done twice a day everyday for fourweeks. With this type of conservative treatment the ath-lete did not see much improvement and continued to pro-gressively get worse after each lifting and conditioningsession. After a month of conservative treatment, the ath-lete began to contemplate having surgery and ending hisfootball career. Because the athlete was not makingprogress, clinician one asked another clinician to take overhis case. Intervention – Clinician 2 During weeks 5-11, this new cli-nician changed the focus of treatment by addressing the ath-lete’s specific impairments of faulty posture via activation andinhibition of specific muscles tochange position of bones andsoft tissue rather than throughverbal education alone. Faultyposture noted via visual observa-tion included: over-developed latissimus dorsi, pectoralis, biceps, and upper trapezius muscles, over-active anteriorneck muscles, increased lumbar lordosis (anterior pelvictilt with left forward rotation), elevated ribs, downwardlyrotated scapula, and forward head posture. Exercises andmanual therapy techniques developed by the PosturalRestoration Institute™ 40 were utilized to optimize postureof the trunk/scapula and pelvis via activation, inhibition,and lengthening of specific muscles. The initial exercises were prescribed in order to restore anormal pelvic and rib cage position (from left pelvic ante-rior tilt/forward rotation and elevated, externally rotatedribs toward neutral) by doing a90/90 hip shift with hemibridgeand balloon (Figure 1) . The exer-cise activated left hamstringmuscles which facilitate left hipextension (posterior pelvic tilt).Forced exhalation into the bal-loon should activate transversusthoracis (triangularis sterni),internal and external inter-costals, and abdominal obliquemuscles which facilitate depres-sion/internal rotation of the ribsand inhibition of paraspinal Figure 1. 90/90 hip shift exercise North American Journal of Sports Physical Therapy | Volume 4, Number 4 | November 2009 |Page 173


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