What are the common symptoms of chest wall syndrome. How is chest wall pain diagnosed. What are the most effective treatments for chest wall syndrome. When should you seek medical attention for chest pain.

Understanding Chest Wall Syndrome: An Overview

Chest wall syndrome encompasses a group of conditions that cause pain in the structures surrounding and protecting the lungs, including the ribs and sternum. This type of discomfort can be easily mistaken for more serious cardiac issues, making it crucial to understand its unique characteristics and potential causes.

The pain associated with chest wall syndrome can manifest in various ways, including:

• Aching or stabbing sensations
• Sharp or burning pain
• Discomfort that worsens with movement or breathing
• Localized tenderness in the chest area

While these symptoms can be alarming, it’s important to note that chest wall syndrome is often less serious than other causes of chest pain. However, proper diagnosis and treatment are essential for managing symptoms and improving quality of life.

Common Causes of Chest Wall Pain

Chest wall pain can stem from a variety of sources, ranging from musculoskeletal issues to underlying medical conditions. Understanding these potential causes can help in identifying and addressing the root of the problem.

Musculoskeletal Conditions

Musculoskeletal problems are the most frequent culprits behind chest wall pain. These can include:

• Costochondritis: Inflammation of the cartilage connecting the ribs to the breastbone
• Tietze’s syndrome: A condition similar to costochondritis but accompanied by swelling
• Intercostal muscle strain: Overuse or injury to the muscles between the ribs
• Slipping rib syndrome: A condition where the lower ribs move excessively, causing pain
• Fibromyalgia: A chronic condition characterized by widespread musculoskeletal pain

Other Medical Conditions

While less common, chest wall pain can also be attributed to:

• Lung problems such as pneumonia or pulmonary embolism
• Cardiovascular issues like angina or pericarditis
• Gastrointestinal conditions including GERD or gallstones
• Rheumatic diseases such as rheumatoid arthritis or ankylosing spondylitis

Diagnosing Chest Wall Syndrome: What to Expect

Accurately diagnosing chest wall syndrome requires a comprehensive approach. Healthcare providers typically begin with a thorough medical history and physical examination. During this process, they may ask about the nature of your pain, any recent injuries, and your overall health status.

Is imaging necessary for diagnosing chest wall syndrome? In many cases, yes. Diagnostic tests may include:

• Chest X-rays to rule out fractures or lung issues
• Musculoskeletal ultrasounds to examine soft tissue structures
• Nerve conduction studies to assess nerve function
• Electrocardiograms (ECG) to evaluate heart function

For more complex cases, additional tests such as CT scans, MRIs, or specialized cardiac assessments may be recommended to rule out other potential causes of chest pain.

Treatment Options for Chest Wall Syndrome

The approach to treating chest wall syndrome varies depending on the underlying cause. However, several common strategies can help alleviate symptoms and promote healing.

Conservative Management

For many cases of chest wall pain, particularly those stemming from musculoskeletal issues, conservative treatments are often effective. These may include:

• Rest and activity modification to avoid aggravating movements
• Application of heat or ice to reduce pain and inflammation
• Over-the-counter pain relievers such as ibuprofen or naproxen
• Gentle stretching exercises to improve flexibility and reduce muscle tension

Medical Interventions

When conservative measures aren’t sufficient, healthcare providers may recommend more targeted treatments:

• Prescription-strength anti-inflammatory medications
• Muscle relaxants to alleviate tension in the chest wall
• Corticosteroid injections for severe or persistent inflammation
• Physical therapy to strengthen muscles and improve posture

For chest wall pain related to specific medical conditions, treatment will focus on addressing the underlying issue. This may involve antibiotics for infections, medications for rheumatic diseases, or specialized cardiac treatments when appropriate.

Prevention Strategies for Chest Wall Syndrome

While not all cases of chest wall syndrome can be prevented, certain strategies may help reduce the risk or severity of symptoms:

• Maintaining good posture to reduce strain on chest muscles and joints
• Practicing proper lifting techniques to avoid injury
• Engaging in regular, low-impact exercise to strengthen chest and core muscles
• Managing stress through relaxation techniques or mindfulness practices
• Avoiding activities that consistently trigger chest wall pain

Can lifestyle modifications really make a difference in preventing chest wall syndrome? Absolutely. By adopting these preventive measures, individuals can significantly reduce their risk of developing or exacerbating chest wall pain.

When to Seek Medical Attention for Chest Pain

While chest wall syndrome is often benign, it’s crucial to recognize when chest pain requires immediate medical evaluation. Seek emergency care if you experience:

• Sudden, severe chest pain accompanied by shortness of breath
• Chest pain that radiates to the arm, jaw, or back
• Pain associated with dizziness, sweating, or nausea
• Any chest discomfort in individuals with known heart disease or significant risk factors

Is it possible to distinguish between chest wall pain and a heart attack? While some characteristics may differ, it’s always safest to seek professional medical evaluation for any concerning chest pain, especially if you’re unsure of its origin.

Living with Chest Wall Syndrome: Long-term Management

For individuals dealing with chronic or recurrent chest wall pain, developing a long-term management strategy is essential. This often involves a multifaceted approach:

Ongoing Self-Care

Incorporating daily practices to maintain chest wall health can make a significant difference:

• Regular stretching routines targeting chest and upper body muscles
• Use of ergonomic tools and furniture to reduce strain during daily activities
• Maintaining a healthy weight to reduce pressure on the chest wall
• Practicing stress-reduction techniques to minimize tension-related pain

Working with Healthcare Providers

Establishing a collaborative relationship with your healthcare team is crucial for effective long-term management:

• Regular check-ups to monitor progress and adjust treatment plans as needed
• Exploring complementary therapies such as acupuncture or massage therapy
• Discussing any new or changing symptoms promptly
• Considering psychological support if chronic pain impacts mental health

How can patients actively participate in their chest wall syndrome management? By staying informed, adhering to treatment plans, and maintaining open communication with healthcare providers, individuals can play a proactive role in managing their condition and improving their quality of life.

Advances in Chest Wall Syndrome Research and Treatment

The field of chest wall syndrome research continues to evolve, offering hope for improved diagnostic and treatment options. Recent advancements include:

Diagnostic Innovations

• Advanced imaging techniques for more precise identification of musculoskeletal issues
• Genetic testing to identify predispositions to certain rheumatic conditions
• Artificial intelligence-assisted analysis of symptoms and medical histories for faster, more accurate diagnoses

Treatment Breakthroughs

• Development of targeted pharmacological therapies for specific types of chest wall pain
• Advancements in minimally invasive surgical techniques for severe or persistent cases
• Integration of virtual reality and biofeedback in physical therapy protocols

What does the future hold for chest wall syndrome treatment? As research progresses, we can expect more personalized and effective treatment options, potentially leading to better outcomes and improved quality of life for those affected by chest wall syndrome.

Understanding chest wall syndrome is crucial for both patients and healthcare providers. By recognizing its symptoms, causes, and treatment options, individuals can seek appropriate care and manage their condition effectively. While chest wall pain can be concerning, with proper diagnosis and treatment, most people can find relief and return to their normal activities. As research continues to advance, we can look forward to even more effective strategies for managing and preventing chest wall syndrome in the future.

Symptoms, Treatment, and Possible Causes

Overview

Chest wall pain is the type that feels like it’s coming from your breast, rib cage, or a muscle in your chest. The chest wall usually refers to the structures surrounding and protecting your lungs, including your ribs and sternum.

You may feel pain only when you do certain movements or only if pressure is applied to your chest wall. You can feel it on one side of your chest or spread across a wide area.

If you go to the emergency room for chest wall pain, most doctors will want to make sure your pain isn’t being caused by a heart attack or another serious problem. While a heart attack can cause chest wall pain, more commonly, chest wall pain is caused by other conditions, including muscle, lung, or digestive issues. How long your chest wall pain lasts and what treatment you receive depends on what’s causing it.

Chest wall pain may be described as:

• aching
• stabbing
• sharp
• burning
• tearing
• pain that worsens when you move your chest, twist your torso, or raise your arms
• pain that increases when you breathe deeply, sneeze, or cough

Other symptoms include:

• numbness
• tingling
• shooting pain that extends to your back or neck

Musculoskeletal conditions are the most common causes of chest wall pain, but there are many other conditions that can lead to pain in the chest wall. Your chest is made up of many muscles, bones, and organs. For this reason, the exact cause of chest wall pain can sometimes be difficult to diagnose.

Some common causes of chest wall pain include:

Musculoskeletal problems

• injury or trauma to your chest, such as from a car accident
• costochondritis
• Tietze’s syndrome, which is similar to costochondritis
• slipping rib syndrome, or lower rib pain syndrome
• intercostal muscle strain or pulled chest muscle
• stress fracture in your ribs
• nerve entrapment
• fibromyalgia
• rheumatic diseases, such as rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis

Lung problems

• pneumonia
• pulmonary embolism

Cardiovascular problems

• heart attack
• angina
• pericarditis
• myocarditis

Gastrointestinal conditions

• peptic ulcer
• gastroesophageal reflux disease
• gall stones

Your doctor will ask about your symptoms and family and personal medical history. Be sure to tell your doctor about any underlying conditions you have, medications you are taking, and if you have recently suffered any injuries.

If your doctor suspects you have a musculoskeletal problem like a rib fracture or costochondritis, they may check along your ribs, chest, and sternum for areas of swelling. They may try to reproduce or trigger your pain to help them learn more about where your pain is coming from.

Other tests to help your doctor evaluate musculoskeletal sources of chest wall pain include:

• chest X-ray
• nerve conduction velocity tests
• electromyography
• musculoskeletal ultrasound
• sympathetic skin response, which is a test of your nerve’s reaction when triggered with stimuli

If you have any risk factors for heart disease, such as diabetes, obesity, high blood pressure, or a history of smoking, your doctor may want to test your heart function. Some of these tests include:

• exercise stress tests
• electrocardiogram
• echocardiogram
• blood tests

If your doctor suspects a problem with your lungs, diagnostic tests may include:

• CT scan to produce a more detailed picture of your lungs
• thoracentesis
• bronchoscopy

Treatment for chest wall pain will vary depending on the cause.

• Musculoskeletal problems. These conditions are managed with heat or ice, anti-inflammatory drugs such as ibuprofen (Advil) or naproxen (Aleve), muscle relaxers, stretching, and physical therapy. You should also try to avoid activities that aggravate your pain. For more severe or persistent cases, your doctor may suggest corticosteroid injections to help reduce inflammation.
• Rheumatic conditions. Treatment of chest wall pain is part of the overall management of each of these conditions. Your doctor will help you decide which is medication is best for you.
• Lung infections. Like other infections, lung conditions such as pneumonia are typically treated with antibiotics.

If your chest wall pain is caused by a heart attack or other serious heart condition, you may receive blood thinners or medications that open arteries. Other treatments include:

• cardiac catheterization
• coronary artery bypass grafting or bypass surgery

Since most cases of chest wall pain are caused by musculoskeletal conditions, the outlook is typically very good. Most people can make a full recovery with rest and physical therapy over the course of a few weeks.

Other causes of chest wall pain can be managed with medications and other treatments, but this depends on the severity of the condition. Treatments for rheumatoid arthritis, for example, can help to manage your pain, control the inflammatory response, and eventually lead to remission.

Heart attacks and pulmonary embolisms can be life-threatening if left untreated. You should seek emergency medical care right away if you have any of the following symptoms along with chest wall pain:

• shortness of breath
• sudden and severe pain in your lungs
• lightheadedness, weakness, dizziness, or fainting
• cough with dark-colored sputum or blood
• dark red or black stools
• nausea
• high fever

Symptoms, Treatment, and Possible Causes

Overview

Chest wall pain is the type that feels like it’s coming from your breast, rib cage, or a muscle in your chest. The chest wall usually refers to the structures surrounding and protecting your lungs, including your ribs and sternum.

You may feel pain only when you do certain movements or only if pressure is applied to your chest wall. You can feel it on one side of your chest or spread across a wide area.

If you go to the emergency room for chest wall pain, most doctors will want to make sure your pain isn’t being caused by a heart attack or another serious problem. While a heart attack can cause chest wall pain, more commonly, chest wall pain is caused by other conditions, including muscle, lung, or digestive issues. How long your chest wall pain lasts and what treatment you receive depends on what’s causing it.

Chest wall pain may be described as:

• aching
• stabbing
• sharp
• burning
• tearing
• pain that worsens when you move your chest, twist your torso, or raise your arms
• pain that increases when you breathe deeply, sneeze, or cough

Other symptoms include:

• numbness
• tingling
• shooting pain that extends to your back or neck

Musculoskeletal conditions are the most common causes of chest wall pain, but there are many other conditions that can lead to pain in the chest wall. Your chest is made up of many muscles, bones, and organs. For this reason, the exact cause of chest wall pain can sometimes be difficult to diagnose.

Some common causes of chest wall pain include:

Musculoskeletal problems

• injury or trauma to your chest, such as from a car accident
• costochondritis
• Tietze’s syndrome, which is similar to costochondritis
• slipping rib syndrome, or lower rib pain syndrome
• intercostal muscle strain or pulled chest muscle
• stress fracture in your ribs
• nerve entrapment
• fibromyalgia
• rheumatic diseases, such as rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis

Lung problems

• pneumonia
• pulmonary embolism

Cardiovascular problems

• heart attack
• angina
• pericarditis
• myocarditis

Gastrointestinal conditions

• peptic ulcer
• gastroesophageal reflux disease
• gall stones

Your doctor will ask about your symptoms and family and personal medical history. Be sure to tell your doctor about any underlying conditions you have, medications you are taking, and if you have recently suffered any injuries.

If your doctor suspects you have a musculoskeletal problem like a rib fracture or costochondritis, they may check along your ribs, chest, and sternum for areas of swelling. They may try to reproduce or trigger your pain to help them learn more about where your pain is coming from.

Other tests to help your doctor evaluate musculoskeletal sources of chest wall pain include:

• chest X-ray
• nerve conduction velocity tests
• electromyography
• musculoskeletal ultrasound
• sympathetic skin response, which is a test of your nerve’s reaction when triggered with stimuli

If you have any risk factors for heart disease, such as diabetes, obesity, high blood pressure, or a history of smoking, your doctor may want to test your heart function. Some of these tests include:

• exercise stress tests
• electrocardiogram
• echocardiogram
• blood tests

If your doctor suspects a problem with your lungs, diagnostic tests may include:

• CT scan to produce a more detailed picture of your lungs
• thoracentesis
• bronchoscopy

Treatment for chest wall pain will vary depending on the cause.

• Musculoskeletal problems. These conditions are managed with heat or ice, anti-inflammatory drugs such as ibuprofen (Advil) or naproxen (Aleve), muscle relaxers, stretching, and physical therapy. You should also try to avoid activities that aggravate your pain. For more severe or persistent cases, your doctor may suggest corticosteroid injections to help reduce inflammation.
• Rheumatic conditions. Treatment of chest wall pain is part of the overall management of each of these conditions. Your doctor will help you decide which is medication is best for you.
• Lung infections. Like other infections, lung conditions such as pneumonia are typically treated with antibiotics.

If your chest wall pain is caused by a heart attack or other serious heart condition, you may receive blood thinners or medications that open arteries. Other treatments include:

• cardiac catheterization
• coronary artery bypass grafting or bypass surgery

Since most cases of chest wall pain are caused by musculoskeletal conditions, the outlook is typically very good. Most people can make a full recovery with rest and physical therapy over the course of a few weeks.

Other causes of chest wall pain can be managed with medications and other treatments, but this depends on the severity of the condition. Treatments for rheumatoid arthritis, for example, can help to manage your pain, control the inflammatory response, and eventually lead to remission.

Heart attacks and pulmonary embolisms can be life-threatening if left untreated. You should seek emergency medical care right away if you have any of the following symptoms along with chest wall pain:

• shortness of breath
• sudden and severe pain in your lungs
• lightheadedness, weakness, dizziness, or fainting
• cough with dark-colored sputum or blood
• dark red or black stools
• nausea
• high fever

Thoracic outlet compression

Home Thoracic outlet compression

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Superior Outlet Syndrome – KinesioPro

The term Thoracic Outlet Syndrome (SVA) describes a condition in which the nerves of the brachial plexus and subclavian vessels are compressed at the thoracic outlet. The space where these structures are compressed is limited by the anterior scalene muscle in front, the middle scalene muscle behind and the first rib from below.

This condition has become one of the most controversial topics in medicine and the rehabilitation of musculoskeletal diseases. The existing controversy extends to almost all aspects of pathology, including definition, frequency, pathological contribution, diagnosis and treatment.

The term CBA does not define a compressible structure. Researchers identify two main categories of SVA: the vascular form (arterial or venous), which causes few problems, and the neurological form, which occurs in more than 95-99% of SVA cases. Therefore, this syndrome should be differentiated using the terms arterial SVA (ACVA), venous SVA (VSVA), or neurogenic (NSVA).

Clinically Significant Anatomy

The first area where vessels and nerves can be compressed is the most proximal and is called the triscalene triangle. This triangle is bounded by the scalenus anterior anteriorly, the scalene medius posteriorly, and the medial surface of the first rib inferiorly. The presence of the scalenus minor and the fact that both the anterior and middle scalenes attach to the first rib can narrow this space and therefore compress the nerves of the brachial plexus and subclavian artery.

The second region is called the costoclavicular triangle, and is bounded anteriorly by the middle third of the clavicle, posteromedially by the first rib, and posterolaterally by the upper edge of the scapula. Here pass the subclavian vein, artery and nerves of the brachial plexus, which then go into the subcoracoid process. Compression of these structures can occur as a result of congenital anomalies, trauma to the first rib or clavicle, and structural changes in the subclavian muscle or coracocostal ligament.

The last area is called the subcoracoid space or the space under the pectoralis minor. This space is located under the coracoid process and the tendon of the pectoralis minor muscle. From above, it is limited by the coracoid process, in front – by the pectoralis minor muscle, and behind – by 2-4 ribs. Shortening of the pectoralis minor muscle can lead to narrowing of this space and, consequently, to compression of the neurovascular structures during hyperabduction.

Some anatomical anomalies can also narrow the superior aperture. These include the presence of a cervical rib, congenital soft tissue anomalies, clavicle hypomobility, and functionally acquired anatomical changes. Soft tissue anomalies can create a compressive effect on the neurovascular structures located at this site (eg, muscle hypertrophy or wider attachment of the middle scalene muscle to the 1st rib).

Epidemiology/Etiology

SVA affects approximately 8% of the population and occurs 3-4 times more often in women than in men aged 20 to 50 years. Women have less developed muscles, a greater tendency to droop the shoulder girdle due to additional breast tissue, and a narrowed superior aperture. These factors change the angle between the scalene muscles and therefore cause a higher prevalence in women. The average age of people suffering from SVA is 30-40 years. This condition is rarely seen in children. Almost all cases of SVA (95-98%) affect the brachial plexus; in other cases (2-5%), vascular structures such as the subclavian artery and vein are affected.

There are several factors that can cause SVA. Cervical ribs are present in about 0.5-0.6% of the population, 50-80% of which are bilateral and 10-20% cause symptoms; the ratio of women to men is 2:1. The cervical ribs and their associated fibromuscular masses are responsible for most cases of SVA. Fibromuscular masses are a more common cause of SVA than rib anomalies.

Congenital factors

• Neck ribs.
• Elongated transverse process of a vertebra.
• Muscle anomalies.
• Fibromuscular formations (transverse costal, costocostal).
• Attachment anomalies of the scalene muscles.
• Exostosis of the first rib.
• Scoliosis.
• High shoulder blade position.
• Location of the subclavian artery or vein in relation to the scalenus anterior.

Acquired fortunes

• Postural changes.
• Lowering of the shoulder girdle.
• Heavy mammary glands.
• Trauma.
• Collarbone fracture.
• Rib fracture.
• Whiplash, neck injury during hyperextension.
• Repetitive injuries (most often formed when sitting at the keyboard for long hours).

Muscular causes

• Scalene muscle hypertrophy.
• Decreased tone of the trapezius, levator scapula and rhomboids muscles.
• Shortening of the scalenes, trapezius, levator scapula and pectoral muscles.

Clinical presentation

Signs and symptoms of SVA vary from patient to patient depending on the location of the nerve and/or vessel involved, which may include changes in sensation or mild pain.

Patients with SVA may experience pain or paresthesias in the face, nape, neck, shoulder, chest, and upper extremity. The patient may also complain of altered or absent sensations, weakness, fatigue, and a feeling of heaviness in the arm and hand. The skin may be marbled or pale. A change in the temperature of the limb may also be observed.

These symptoms are usually worse when the arm is above the head and turned outward and the head is turned to the same or opposite side. Activities such as throwing a ball overhead, pitching a tennis ball, painting the ceiling, driving, or typing can make symptoms worse.

When the superior nerves of the brachial plexus (C5, 6, 7) are involved, pain may occur in the lateral aspect of the neck, extending to the ear and face, as well as to the interscapular region behind and infraclavicular region in front. The pain can move down the arm, in the projection of the radial nerve. There may also be headaches.

Patients with involvement of the inferior nerves of the brachial plexus (C8, Th2) typically have symptoms that are located in the anterior and posterior region of the shoulder and extend down the ulnar side of the forearm to the hand, ring finger, and little finger.

There are four categories of SVA, each with unique signs and symptoms. As a rule, SVA does not correspond to the dermatome or myotomy scheme, unless there is nerve root involvement, which will be important in substantiating the diagnosis and planning treatment.

Arterial SVA

• A young man who actively uses his hands.
• Pain in the arm.
• Pale.
• Cold intolerance.
• Paresthesia.
• Symptoms appear spontaneously.

Venous SVA

• A young man who actively uses his hands.
• Cyanosis.
• Feeling of heaviness.
• Paresthesia of the fingers and hand (the result of edema).
• Swelling of the hand.

True SVA

• History of neck injury.
• Pain, paresthesia, numbness and/or weakness.
• Pain in the occiput.
• Symptoms may occur day and night.
• Violation of fine motor skills.
• Cold intolerance (possibly Raynaud’s phenomenon).
• Objective weakness.
• Symptoms worse during the day*.

Neurogenic SVA

• History of neck injury.
• Pain, paresthesia and “feeling” weak.
• Pain in the occiput.
• Nocturnal paresthesias that often “wake up” the patient.
• Violation of fine motor skills.
• Cold intolerance (possibly Raynaud’s phenomenon).
• Subjective weakness.
• Symptoms worse at night**.

* – A patient who experiences symptoms throughout the day during certain postures resulting in increased tension or compression of the superior aperture. The most common aggravating postures are forward head position with prostration and shoulder girdle depression, or arm overhead activity. These positions cause an increase in tension/compression, which can lead to increased compression or irritation of the neurovascular bundle.

** – A patient who experiences symptoms at night, which may cause insomnia. This is due to the weakening of tension or compression of the upper aperture, as a result of which the perineural blood supply to the brachial plexus is restored. This is used as an indicator of a favorable outcome and elimination of symptoms.

Differential Diagnosis

Sometimes SVA can be quite difficult to distinguish from other pathologies with similar manifestations. A thorough history taking and evaluation should be carried out to determine if the patient’s symptoms are indeed related to SVA.

The following pathologies are common differential diagnoses for SVA:

• Carpal tunnel syndrome.
• De Quervain’s tenosynovitis.
• Lateral epicondylitis.
• Medial epicondylitis.
• Complex regional pain syndrome (CRPS I or II).
• Horner’s syndrome.
• Raynaud’s disease.
• Cervical lesion (especially discogenic).
• Brachial plexus injury.
• Systemic disorders: inflammatory diseases, diseases of the esophagus or heart.
• Deep vein thrombosis of the upper limb, Paget-Schroetter syndrome.
• Rotator cuff pathology.
• Shoulder shoulder instability.
• Malignant neoplasms (local tumors).
• Chest pain, angina.
• Vasculitis.
• T4 syndrome.
• Sympathetic pain.

Systemic causes of brachial plexus pain include:

• Pancoast syndrome.
• Radiation-induced brachial plexopathy.
• Parsonage-Turner syndrome.

There are conditions that can coexist with SBA. It is important to identify these conditions because they must be considered separately. These associated conditions include:

• Carpal tunnel syndrome.
• Peripheral neuropathies (such as ulnar nerve entrapment, shoulder tendinitis and shoulder joint impingement syndrome).
• Fibromyalgia of the shoulder and neck muscles.
• Degenerative-dystrophic changes in the cervical region (eg, cervical spondylosis and herniated disc).

Rating scales

• DASH (shoulder and hand disability).
• SPADI (Shoulder Pain and Disability Index).
• NPRS (Numerical Pain Rating Scale).
• McGill Pain Questionnaire.

Diagnostic procedures

Diagnosis of SVA is based on history, physical examination, provocation tests and, if necessary, ultrasound, radiological and electroneurophysiological examination. It should always be kept in mind that the diagnosis of SVA is usually confirmed by the exclusion of other causes with a similar clinical presentation. Differential diagnosis of cervical radiculopathies and neuropathies of the upper extremity can be difficult. For an accurate diagnosis, the clinical picture should be assessed as neurogenic (compression of the brachial plexus) or vascular (compression of the subclavian vessels). The manifestations of SVA are varied and there is no single definitive test, making diagnosis difficult.

Score

Below are the general results of the examination obtained in patients with SVA, which should be taken into account. However, this is not a complete list, and the examination should be individual for each patient.

History

Be sure to take a detailed history, identify/rule red flags, and ask the patient how their symptoms affected their function.

Physical examination

Examination

• Posture.
• Cyanosis.
• Edema.
• Pale.
• Atrophy.

Palpation

• Temperature changes.
• Fullness of the supraclavicular fossa.
• Pain in the scalene and trapezius muscles.

Neurological evaluation

Manual testing of the following muscles:

• Scalene muscles.
• Pectoralis major and minor.
• Muscle that lifts the scapula.
• Sternocleidomastoid muscle.
• Serratus anterior.

Special Tests

• Roos Test: Patient abducts arms at 90° and therapist applies pressure to scapula while patient opens and closes fingers. If SVA symptoms recur within 90 seconds, the test is positive.
• Adson test: the patient is asked to turn the head to the affected side and raise the chin. If the pulse on the radial artery on this side is absent or decreases, then the test is considered positive (the vascular component of the neurovascular bundle is compressed by the scalene muscle or cervical rib).
• Wright test: patient’s arm in hyperabduction. If there is a decrease or absence of a pulse on this side, then the test is considered positive (the axillary artery is compressed by the pectoralis minor muscle or the coracoid process due to the tension of the neurovascular bundle).
• Kyriax release: patient sitting or standing. The examiner stands behind the patient and holds the patient’s forearms (with the elbows at 80 degrees of flexion, with the forearms and wrists in a neutral position). The examiner tilts the patient’s torso posteriorly and passively raises the shoulder girdle. This position is held for up to 3 minutes. The test is considered positive if paresthesia and/or numbness (release phenomenon) or other symptoms occur.
• Supraclavicular pressure: the patient is seated, arms at the sides of the body. The examiner places his fingers on the top of the trapezius muscle and the thumb on the anterior scalene muscle at the first rib. The examiner then closes his fingers and holds this position for 30 seconds. If there is a reproduction of pain or paresthesia, then the test is considered positive. This applies to compression of the brachial plexus in the region of the interstitial space.
• Costoclavicular maneuver: This test can be used to detect both neurological and vascular compression. The patient pulls the shoulders back and flexes the chin. A decrease in symptoms means that the test is positive – the neurogenic component of the neurovascular bundle is compressed.
• Brachial plexus tension tests: These tests are designed to affect the neurological structures of the upper limb. The shoulder, elbow, forearm, wrist and fingers are held in a certain position to put stress on a certain nerve (nerve dislocation) and further repositioning of each joint is performed for the purpose of structural differentiation.
• Rotation and lateroflexion: the test is performed with the patient sitting. The cervical spine is passively and maximally rotated away from the side being tested. While maintaining this position, the cervical region gently flexes, moving the ear towards the chest. The test is considered positive if lateroflexion is blocked.

Electroneuromyography (ENMG) can be performed to evaluate patients with SVA. Vascular SVAs can be identified using venography and arteriography.

Imaging can be performed in addition to electrophysiological studies. X-rays of the cervical spine and chest are important to detect bony abnormalities (such as cervical ribs or “elongated C7 transverse processes”).

Treatment

Non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed to reduce pain and inflammation. Injections of botulinum toxin type A into the anterior and middle scalene muscles temporarily relieve pain and spasm from vascular compression. Surgical treatment of SVA should only be considered after the failure of conservative treatment has been proven. Also indications for surgical treatment are rapidly increasing symptoms. Surgery for the treatment of SVA can be performed using several different approaches, including: transaxillary, supraclavicular, and subclavian approaches.

For venous or arterial SVA, drugs can be administered to dissolve the clots. A procedure may also be performed to remove a blood clot from a vein or artery.

In some women with larger breasts, the shoulders droop, which increases the pressure on the neurovascular structures in the region of the superior aperture. A supportive bra with wide straps that criss-cross at the back can help reduce tension. In extreme cases, breast reduction surgery may be considered to alleviate the symptoms of SVA and other biomechanical problems.

Physical therapy

Medical treatment should be the first treatment strategy for SVA as it is effective in reducing symptoms and improving function. Conservative treatment includes physical therapy, which focuses mainly on patient education, pain control, increased range of motion, improved nerve gliding, and muscle strengthening.

First stage

The purpose of the initial stage is to reduce the patient’s symptoms. This can be achieved by educating the patient about SVA and incorrect posture. In addition, the patient is explained his prognosis and the importance of following the doctor’s recommendations. People who sleep with their arms up need to be informed about their posture so they don’t wake up at night. These patients should sleep on their healthy side or in the supine position, possibly with their sleeves fastened. If the patient has a “release phenomenon”, then a Kyriax release may be used. This method completely unloads the neurovascular structures in the region of the upper aperture before going to bed.

Kyriax release maneuver

• Elbows flexed 90°.
• Towels create a passive lift of the shoulder girdle.
• Supported spine and head in neutral position.
• The position is held until peripheral symptoms appear.

The patient’s breathing technique should be assessed as the scalenus and other accessory muscles often compensate for the major respiratory muscles during inhalation. Encouraging diaphragmatic breathing will reduce stress on already overworked or tense muscles and possibly reduce symptoms.

Scapular Operation

This is important for normal scapular muscle recruitment and control at rest. Once this is achieved, it is necessary to move on to improving the control of the scapula during movement and under load. Training starts at lower abduction ranges and gradually progresses further into abduction and flexion until the muscles are retrained to work within higher amplitudes.

Humeral head control

It is also important to control the position of the humeral head. The most common violation is the anterior location of the head of the humerus. Moderate isometric contraction of the rotator cuff muscles by applying resistance to the humeral head is a useful strategy to help stabilize and centralize the humeral head.

This can then be integrated into movement patterns during treatment. First in exercises with slow controlled concentric/eccentric movement, then in isolation exercises to strengthen the muscles.

Serratus anterior recruitment and control

The external rotation and abduction strategies described above are often sufficient to recruit and control the serratus anterior without the risk of over-activating the pectoralis minor.

Second stage

Once the patient has reduced his symptoms, he can proceed to this stage of treatment. The purpose of this step is to directly target the tissues that create structural constraints. How this should be done is one of the most discussed topics. Here are some options that are discussed in the literature.

• Massage.
• Strengthen the levator scapula, sternocleidomastoid, and superior trapezius muscles (this muscle group “opens” the superior aperture, elevating the shoulder girdle and enlarging the costoclavicular space).
• Stretching of the pectoral muscles, lower trapezius and scalene muscles (these muscles “close” the upper aperture).
• Posture correction exercises.
• Relaxation of shortened muscles.
• Aerobic exercise in a daily home workout program.
  • Exercises for the shoulder girdle and restoring range of motion and increasing space for neurovascular structures. Raise your shoulders and pull them back, flex your upper thoracic spine and move your shoulders forward and down. Then straighten your back and repeat the exercise 5-10 times.
  • Amplitude of movement of the cervical spine. Standing with your back to the wall (touching the back of your head), lower your chin to your chest (5-10 reps). The effectiveness of this exercise can be increased by pressing your hands down on your head.
  • The activation of the scalene muscles is the most important point. Exercises are performed in isometric mode for 5 seconds. Anterior scalene muscle – press your forehead into your palm; scalene medius – press on the palm with the side of the head; posterior scalene muscle – press the back of the head into the palm of your hand.
  • Stretching exercises.

Other activities

• Mobilization of the shoulder girdle: cervicothoracic, sternoclavicular, acromioclavicular and costotransverse joints.
• Mobilization of the humeroscapular joint at the end of the shoulder lift amplitude with elbow support in extension.
• Taping: Some patients with severe symptoms respond well to taping and orthoses that raise or retract the shoulder girdle.

Manual therapy and first rib mobilization

First rib mobilization should be done with caution and only after careful evaluation, as this can cause irritation and pain symptoms in some patients.

• Posterior glide of the humeral head with arm flexion. The patient lies on his back. The mobilizing hand touches the proximal humerus, avoiding the coracoid process. The force is directed backwards (thumb direction).
• Anterior glide of the humeral head with arm grip. The patient is placed in the supine position. The mobilizing hand touches the proximal humerus, avoiding the acromion. The force is directed anterior-medially.
• Inferior sliding of the head of the humerus. The patient is placed in the supine position. The stabilizing arm holds the humerus proximally (distal to the acromion). The mobilizing hand touches the axillary edge of the scapula. Mobilize the scapula in a cranio-medial direction along the chest.
• Mobilization of the first rib. The patient is sitting. A thin belt is placed over the first rib. Pull the strap towards the opposite thigh. Neck in retraction, contralateral lateral flexion and ipsilateral rotation. Ipsilateral head rotation increases the stretching of the scalene muscles. Contralateral rotation enhances the mobilization of the first rib.

Postoperative Physiotherapy

If the patient does require surgery, then physical therapy should follow immediately to prevent scar tissue and return the patient to normal work.

Conclusion

SVA can present in a variety of ways due to the variety of tissues that can be involved (arteries, veins, nerves, and muscle tissue) and the different anatomical sites where compression or pressure can occur. In general, according to a review of the literature by Vanti et al., SVA treatment should be initiated conservatively, but no clear conclusions can be drawn from this review due to a lack of high-quality evidence. Conservative treatment appears to be effective in reducing symptoms, improving function, and facilitating return to work compared with surgery.