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| Peripheral nerve damage, CNS sensitization |
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• arises from compression of the brachial plexus (lower trunk of C8-T1)
• or the subclavian artery / vein as they pass through the superior triangle of the thorax
• bounded by the first rib and scalene muscles. |
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confirmed by nerve conduction studies
• affects lower trunk -> C8-T1 -> ulnar & median nerve distribution |
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a. Arterial- Confirmed by arteriography / MRA / CTA
b. Venous -Confirmed by venography / MRV / color flow duplex US |
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• 10% of cases of TOS have definite signs of vascular or neural compression
o Vascular TOS - Arterial / Venous
o “True” Neurogenic TOS |
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| ______% of symptoms in TOS have neurogenic-type complaints of paresthesias, numbness & pain BUT no positive objective test to identify the source |
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• UE pain , paresthesia, and numbness in the arm may occur diffusely, or over the anterior and posterior shoulder region and radiate down the arm
• or up to the posterior neck to the mastoid process and occipital region of the scull
• may cause severe headaches |
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Definition
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Definition
| • Distal symptoms can be isolated to the ulnar nerve |
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| non-specific neurogenic TOS |
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Definition
| more global – sometimes a “glove-like distribution” |
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| overhead activities, static postures, driving,night wakening, fatigue of arm and hand |
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Definition
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o Ischemic signs and symptoms - cool and numb, pale and pulseless
o Venous compression - Edema and cyanosis, warm with distended veins |
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Definition
| vascular TOS additiona signs and symptoms |
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• Adson’s, Hallstead’s (add traction to hand and contralateral rotation)
• Roo’s- Hold for 3 min while opening and closing hands |
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Definition
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Definition
• Introduced by Elvey
• Popularized by Butler
• Attempt to isolate stretch to
o Median
o Ulnar
o Radial |
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Definition
| • Several anatomical studies have shown that the ULTT1 specifically stretches |
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| addition of neck side flexion |
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Definition
| does not add tension to the nerve, nor does it selectively stretch any nerve roots |
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• Sensitivity was 0.97
• Specificity was 0.22 |
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Definition
| ULTT sensitivity and specificity |
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Definition
purported to be a dural stretch via:
o upward pull from cervical flexion
o downward pull from the sciatic nerve
• Equally important is the effect of spinal posture of on the sympathetic trunk |
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• C/S extension
• C/T protrusion
• T/S flexion
• L/S extension |
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Definition
| sympathetic trunk stretched by |
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always check!
• esp after MVA / whiplash
• eg cervical rotation / lateral flexion (CRLF)
• Lindgren et al (1992) found the CRLF to have high inter-testor reliability and high correlation with radiographic position of the 1st rib |
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Definition
• Isometric neck flexion will reverse weakness of ADD POLL and FPB
• Also FCU (ulnar nerve)
• Edgelow has developed a thumbometer to measure |
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Definition
• Upton & McCommas (1973) found that 70% of 115 patients with either carpal tunnel syndrome or ulnar neuropathy also showed neurophysiological evidence of a cervicothoracic root lesion
• Proximal insult is asymptomatic but changes axoplasmic flow enough that distal entrapment becomes symptomatic |
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• Significant symptoms with normal electrodiagnostic findings
• Positioning joints proximal to area of symptoms changes symptoms
•certain positions provoke and give significant relief
• Pressure-provocative tests can demonstrate entrapment points along the nerves
• Holding provocative positions
• Dynamic nerve compression – may only find evidence of compression when patient’s symptoms are provoked in the offending positions |
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Definition
| assesment of double crush syndrome |
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Term
palpate at local sites
apply pressure at site in provocative positions
strtch whole nerve (ULTT) compress the final site.
if ULTT + by itself, back off several joints |
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Definition
| nerve palpation progression |
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Definition
• Proximally can palpate in bicipital furrow
• Distally can palpate proximal to carpal tunnel |
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Definition
• 3 locations:
o Guyons canal
o Cubital tunnel
o Medial arm |
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Definition
• 4 fb above styloid process on lateral radius
• Slide under extensor origin at elbow
• 3 fb below deltoid insertion |
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| brachial plexus TOS palpation |
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Definition
• Supraclavicular palpation
• Locate scalenes with gentle side flexion then press behind ant scalene
• Move inferior to 1st rib |
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• Main goal is to change scapular positioning to avoid excessive traction / compression
• Stretch tight muscles, strengthen weak ones
• Encourage axial extension with spinal exercises and mobilizations, facilitated by taping
• May also need to address myofascial component
• R/O referred cervical pain and elevated first rib |
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Definition
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| protection of the viscera |
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Definition
| takes precedence over spinal mobility |
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Definition
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Definition
less frequent than in cervical and lumbar spine
o they are harder to correct with repeated movements
o they commonly refer pain to the chest, rather than the extremities
o if there is nerve root impingement - it is the intercostal nerves |
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Definition
more common
o they usually create localized hypomobility
o instability is seldom a problem (except at the thoraco-lumbar junction)
o They seldom result in long-term problems |
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Definition
Thoracic referral can mimic visceral pain and vice versa
Look to the thoracic spine in patients with S/S of sympathetic involvement
Be prepared for S/S of sympathetic hyperactivity after treatment directed to the thoracic spine |
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Definition
Incidence (via imaging) is reportedly low
2% of back pain patients
Most common between T8-T12 |
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o Location not sharp / localized
o Pain at rest
o Pain after prolonged flexion
o Pain with loading
o PDM not just ERP |
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Definition
| thoraci disc lesion assesment findings |
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| much more likely to be referred from a cervical disc |
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Definition
• Spread of symptoms always includes the hand
o Distribution is glove-like
• No neurological signs
• Worse at night or upon rising
o (aka: “nocturnal paraesthetic brachialgia”)
• CAUSE ?
o Via the autonomic nervous system ?
• Treatment ?
o Mobilize Thoracic segments -> posture / exercise |
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Definition
Commonly described as “opening” or “closing” lesions
presumed to be “stuck” or “held” in a position
o flexed = “opened”
o extended = “closed” |
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Definition
| o When the thoracic spine is in neutral, and the facets and ligaments are not engaged - side bending and rotation occur to the opposite side |
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Definition
| o When the thoracic spine is flexed or extended, and the facets and/or ligaments are engaged - side bending and rotation occur to the same side |
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Definition
Named by the position in which they are held
An FRSR is held in Flexion, Right Rotation and Right Side flexion
This is opposite to the movement restriction
An FRSR cannot extend, Left Rotate and Left Side flex |
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Definition
• First assess whether right or left rotation is more painful / restricted
• Repeat the painful /restricted rotation in flexion and then in extension
• If worse in flexion –they have an ESR
• If worse in extension – they have an FSR |
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o MET first choice / or can also use a SNAG
o Grades 1 - 2 mobs
o Rarely use HVT |
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Definition
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o MET still worth a try
o Grades 3 - 4 mobs, with follow-up exs
o Use HVT if MET / mobs don’t work |
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Definition
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Definition
Rib angle less prominent posteriorly, Rib angle appears medially displaced
No change with flexion / extension, Inhalation and exhalation both restricted |
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| posterior rib subluxation |
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Definition
Rib angle more prominent posteriorly
Rib angle appears laterally displaced
No change with flexion / extension
Inhalation and exhalation both restricted |
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| anterior-posterior compression |
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Definition
Rib flattened anteriorly and posteriorly
Rib shaft prominent mid-axillary
No change with flexion / extension
Inhalation and exhalation both restricted |
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Definition
Rib prominent anteriorly and posteriorly
Rib shaft flattened mid-axillary
No change with flexion / extension
Significant restriction of both inhalation and exhalation for that rib |
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Definition
Usually ribs 2-4 (like subluxed 1st rib)
Ipsilateral shoulder and arm complaints
Prominent rib shaft mid-axillary
TOP pectoralis minor
Exhalation restricted more than inhalation |
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Definition
Position changes with flexion / extension
Rib borders unequal
– External torsion lose inferior border of rib and decrease of intercostal space below
– Internal torsion lose superior border of rib and decrease of intercostal space above
Restriction of inhalation / exhalation |
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Definition
Make your best guess as to the diagnosis
Anterior (costochondral) pain and TOP is common to all of these dysfunctions
Retest for anterior TOP post correction
Note: subluxed ribs are already hypermobile - therefore do not use thrust techniques - use METs instead |
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| order of treatment for structural ribs |
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Definition
Thoracic spine before ribs
Exception is torsion, which can be corrected at same time as thoracic spine
Then structural rib dysfunctions
Lastly inhalation / exhalation restrictions |
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Definition
| formed of very thin compact bone – not designed for vertical loading – i.e. it is non-articular |
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Definition
| o the articular eminence (of temporal bone) is separated from the articular tubercle by the |
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Definition
| o articulating surfaces lined with ________________, esp. anteriorly on articular eminence and the corresponding anterior condyle |
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| posterior attachment of TMJ articular disc |
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Definition
| superior/inferior lamina + retrodiscal pad which is highly innervated and vascular and hence subject to inflammation and TOP |
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| capsule and ligaments of TMJ |
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Definition
o richly innervated and lined with a highly vascular synovial membrane
o collateral ligaments attach to the disc - forming a “self-seating mechanism” on closure |
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Definition
o Temporalis
o Masseter
o Medial pterygoid |
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Definition
o Inferior head of lateral pterygoid
o Hyoid muscles |
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contracts on closing to stabilize the disc
(some sources report it attaches to disc in 40-60% of the population) |
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depression (40 mm)
- protrusion (5-7mm)
- lateral excursion (5-7mm) |
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Definition
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| not affected as much by muscles as depression |
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