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A 22-year-old collegiate swimmer presents to an outpatient physical therapy clinic with a primary complaint of right arm pain and numbness in his fourth and fifth fingers. The symptoms began insidiously approximately 6 months ago and have gradually worsened over the past month to the point where he is no longer able to practice with his team. He is right-hand dominant and swims the butterfly and freestyle strokes. He rates the worst pain as 3/10 to 5/10 and the lowest pain as 2/10 on the 0 to 10 visual analog scale. He describes the pain as “dull, deep, achy, and intermittent,” and relates that the symptoms increase throughout the day and with overhead activities. He is occasionally awakened at night with his fingers feeling “numb.” The numbness decreases when he shakes his hand. His goal is to return to competitive swimming in order to maintain his athletic scholarship.

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What are the most appropriate physical therapy interventions?

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What is his rehabilitation prognosis?

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What tests and measures could be performed to confirm or refute your suspected diagnosis?

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Based on this scenario, what diagnoses would you consider?

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  • BRACHIAL PLEXUS: Major nerve plexus innervating the upper limb that consists of the ventral primary rami of the fifth cervical to first thoracic spinal nerves
  • POSTURAL SYNDROMES: Muscular imbalances of the cervical spine, shoulder, and scapular regions that can lead to thickening or fibrosis of certain muscle groups and potentially compress the brachial plexus

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  1. Describe thoracic outlet syndrome (TOS).

  2. Identify key signs and symptoms suggestive of TOS.

  3. Identify constitutional red flag signs and symptoms suggesting systemic pathology.

  4. Determine applicable tests and measures to examine a patient with suspected TOS.

  5. Identify reliable and valid outcome tools to assess TOS.

  6. Discuss possible postural impairments that could lead to TOS and how these impairments could be addressed with physical therapy interventions.

  7. Describe the most effective evidence-based physical therapy interventions utilized to treat TOS.

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PT considerations during management of the individual with thoracic outlet syndrome:

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  • General physical therapy plan of care/goals: Relieve symptoms, improve function, improve posture, prevent recurrence
  • Physical therapy interventions: Postural education; activity modification; increase muscle length and strength impairments through passive and active techniques; improve joint hypomobility through mobilization techniques; restore upper limb neurodynamics
  • Precautions during physical therapy: Presence of constitutional signs/symptoms; increased radicular signs and symptoms including reduced reflexes, sensation loss, or myotomal weakness

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TOS is a multifaceted musculoskeletal condition attributed to compression of neurovascular structures within the thoracic outlet. First coined by Peet1 in 1956, TOS has a variable presentation due to the variety of tissues that can be involved and multiple sites where compression can occur.2-4 The incidence of TOS is 3 to 80 cases/1000 individuals. The condition more commonly affects females, with an 8-9:1 female-to-male ratio....

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