Physiotherapy Theory and Practice, 29(7):562–571, 2013

Copyright © Informa Healthcare USA, Inc.

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593985.2012.757684

CASE REPORT

Diagnosis and treatment of a patient with bilateral

thoracic outlet syndrome secondary to anterior
subluxation of bilateral sternoclavicular joints:
A case report
Deidra Nichols, DPT and Cindy Seiger, PhD, PT
Department of Physical and Occupational Therapy, Idaho State University, Pocatello, ID, USA

ABSTRACT
Thoracic outlet syndrome may result from a posterior sternoclavicular (SC) joint subluxation, or an anterior SC
joint subluxation after surgical fixation. This case report presents the physical therapy management of a patient
with bilateral thoracic outlet syndrome (TOS) secondary to bilateral idiopathic anterior SC joint subluxation. A
16-year-old female presented with a 2-year history of numbness, tingling, and coldness in bilateral upper extre-
mities, and intermittent headaches with occasional vision loss. Ipsilateral upper extremity symptoms were
reproduced with cervical rotation and shoulder flexion and abduction from 90° to end of the range. All TOS
tests were positive. Passive horizontal abduction, through the plane of scaption, produced anterior subluxation
of the ipsilateral SC joint. Sustained posterior glides to the medial clavicle relieved all symptoms during
shoulder flexion and the Adson’s test. Interventions consisted of manual therapy, therapeutic exercise, and
the trial of two orthoses. After 12 treatment sessions, the patient’s symptoms resolved and she improved by
10 points on the Upper Extremity Functional Index. She had no reproduction of symptoms with the thoracic
outlet special tests. She maintained a static hold for 90 sec at 90° shoulder flexion, 90° shoulder abduction,
and full shoulder flexion without symptoms. The outcomes describe a successful intervention for a patient
with bilateral TOS secondary to idiopathic bilateral anterior SC joint subluxation. This case suggests that
SC joint dysfunction should be considered as a cause of TOS and should be screened during the initial
examination.

INTRODUCTION compression of the brachial plexus (neurogenic) is

Thoracic outlet syndrome (TOS) results from com-
pression of the brachial plexus, subclavian artery,
and/or subclavian vein as they pass through the thor-
acic outlet region (Goodman and Fuller, 2009;
Jabar, Rashid, and Lam, 2008). This compression
most commonly occurs at the interscalene triangle,
the costoclavicular triangle, or the subcoracoid space
(Jabar, Rashid, and Lam, 2008). TOS may also be a
result of a cervical rib (Goodman and Fuller, 2009)
or clavicle pseudoarthrosis (Khu and Midha, 2010;
Sales de Gauzy et al, 1999). TOS caused by
Accepted for publication 4 December 2012
Address correspondence to Cindy Seiger, PhD, PT, Department of
Physical and Occupational Therapy, Idaho State University, 921 S 8th
Ave, Stop 8045, Pocatello, ID 83209, USA. E-mail: seigcind@isu.edu
the most common and occurs more often in women
between late adolescence and 50–55 years old
(Jabar, Rashid, and Lam, 2008). Young men and
women are affected equally if the TOS is caused by
the compression of the vascular structures. Idiopathic
TOS predominantly affects adult women. The clinical
manifestations of TOS depend upon which structure
is being compressed and may include numbness,
tingling, parasthesias, muscular weakness, edema,
cyanosis, coldness, or fatigue in the affected upper
extremity (Goodman and Fuller, 2009; Jabar, Rashid,
and Lam, 2008).
TOS was also identified as a possible complication
of a posterior sternoclavicular (SC) joint subluxation
by decreasing the space within the thoracic outlet
region, thus increasing the compression on the neuro-
vascular structures (Robinson, Jenkins, Markham,

562

and Beggs, 2008). Overall, subluxations, partial dislo-
cations due to trauma or joint laxity, of the SC joint
are uncommon and only account for approximately
1% of all joint dislocations, and 2.5–3% of all upper
extremity joint dislocations (Echlin and Michaelson,
2006; Robinson, Jenkins, Markham, and Beggs,
2008; Rockwood and Odor, 1989). SC subluxations
are generally the result of direct or indirect trauma
and can occur anterior or posterior (Robinson,
Jenkins, Markham, and Beggs, 2008; Rockwood and
Odor, 1989). Anterior SC joint subluxations occur
when the medial end of the clavicle is displaced ante-
riorly in reference to the anterior surface of the
sternum, and the posterior SC joint subluxations
occur when the medial end of the clavicle is displaced
posteriorly in reference to the posterior surface of the
sternum. Anterior SC joint subluxations are far more
common and account for 73–95% of all SC joints sub-
luxations (Gleason, 2006). In addition, anterior SC
joint subluxations are typically treated conservatively,
whereas posterior SC joint subluxations are often
treated surgically to prevent cardiovascular compro-
mise (Robinson, Jenkins, Markham, and Beggs,
2008). While TOS is a recognized potential compli-
cation of a posterior SC joint subluxation (Robinson,
Jenkins, Markham, and Beggs, 2008), TOS has only
been associated with an anterior SC joint subluxation
following surgical fixation (Rockwood and Odor,
1989). The purpose of this case report is to present
the physical therapy examination and interventions
for a patient with bilateral TOS secondary to idio-
pathic bilateral anterior SC joint subluxation and to
provide a foundation for future research.
CASE DESCRIPTION
History
A 16-year-old female presented for physical therapy
evaluation and treatment with complaints of numb-
ness, tingling, and coldness in both hands, as well as
intermittent headaches with occasional loss of vision.
She was not referred by a medical doctor, but the
patient and her parent requested and attended this
evaluation as a final effort to resolve the symptoms
prior to obtaining a surgical consult to possibly
remove a rib or part of both clavicles. The symptoms
in her upper extremities did not follow a specific
nerve distribution and were present in all fingers, in
the palmar and dorsal aspects of both hands, and the
volar aspect of both forearms, with the right side
worse than the left. The patient described the tingling
as “needle pricks” that eventually progressed to a
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 563
complete loss of sensation. All of the symptoms were
aggravated by overhead activities. The patient was
independent in performing all of her ADLs and
IADLs, but experienced increased symptoms with
overhead and reaching activities. Because of this, she
was also limited in playing a guitar, total participation
in school classes, and participating in sports and other
school activities.
The symptoms in her upper extremities, the head-
aches, and the vision loss all began approximately 2
years prior to this examination. There was no known
mechanism of injury and the symptoms had progress-
ively worsened since that time. The patient received
multiple medical consultations during the 2 years pre-
ceding the examination, which included examinations
by a pediatrician, a cardiologist, and a neurologist,
and treatment from another physical therapist for
TOS symptoms. The initial physical therapist diag-
nosed her with TOS and prescribed stretches for her
pectoralis muscles, which the patient reported made
her symptoms worse. The patient received multiple
imaging tests that were all negative, including: an
MRI of her head; an X ray of her neck; a CT scan
of her head; an ECG; and multiple blood tests. She
also received bilateral Dopplers of the brachial
arteries, which showed evidence of mild constriction,
and a Holter monitor, which showed evidence of
tachycardia during non-strenuous activities such as
sitting. The patient’s medications included Zoloft
for depression and ibuprofen, naproxen, and acetami-
nophen as needed for her headaches. The patient’s
past medical history was unremarkable, and her
goals for physical therapy were to increase her upper
extremity strength and increase her participation in
sports.
Physical examination
Observation
Posture was observed from the anterior, lateral, and
posterior views in both sitting and standing positions.
The patient demonstrated a forward head and
rounded shoulders posture but was able to self-
correct with verbal cueing. Her right shoulder was
more depressed than the left shoulder. From the
anterior view, the patient had pectus carinatum. In
sitting and standing positions, the medial portions of
both the clavicles at the SC joint appeared to be pro-
truding and more defined than would be expected
for the patient’s weight and body structure. In sitting
position, the lower cervical extensors appeared tense
and overdeveloped, suggesting hypertonicity. She
had no gross abnormalities during walking.
564 Nichols and Seiger
Upper quarter screen
The patient was alert and oriented and had no gross
abnormalities of her integumentary system of the
trunk or upper extremities. Cervical spine active range
of motion was within normal limits and pain-free with
flexion, extension, and bilateral side-bending. Cervical
rotation had full range of motion but increased her
symptoms in the ipsilateral UE and hand. Overpressure
was applied to cervical flexion and side-bending and
was within normal limits and pain free. Cervical resist-
ance testing, with the patient sitting and the spine in
neutral, was strong and pain free in all directions.
There was no observable involvement of the brainstem.
The patient’s bilateral UE active range of motion was
within normal limits for all shoulder, elbow, wrist,
and hand motions. Myotome testing of C5-T1 was
intact and symmetrical bilaterally. Dermatome testing
indicated that C4-T1 light touch sensation was intact
and symmetrical bilaterally. Reflexes (C5–C7) were
normal bilaterally and she was negative for wrist clonus.
Upper Extremity Functional Index
The Upper Extremity Functional Index (UEFI) was
used to determine the patient’s subjective level of dis-
ability. The UEFI has a test–retest reliability coefficient
= 0.95 (two-sided 95% CI = 0.92–0.97) and the
minimal detectable change needed is 9 points (Stratford,
Binkley, and Stratford, 2001). The patient’s initial score
was 70/80, indicating mild disability perceived by the
patient during ADLs and recreational activities.
Mobility and strength
In addition to the range of motion testing performed
during the upper quarter screen, active and passive
TABLE 1 Manual muscle test results during the course of treatment (Palmer and Epler, 1998).
Session 1 (initial)
Capital flexion 3/5
Cervical flexion 3/5
SCM L 3 + /5; R 3/5
Shoulder flexion L 3 + /5; R 4/5
Shoulder abduction L 3 + /5; R 4/5
Horizontal adduction
Sternal L 3 + /5; R 3 + /5
Clavicular L 3 + /5; R 3 + /5
Shoulder ER L 3 + /5; R 4/5
Shoulder IR L 3 + /5; R 3 + /5
Scapular depression L 2/5; R 2/5
L, left; R, right; SCM, sternoclavicular muscle; ER, external rotation; IR, internal rotation.
range of motion was further measured for the gleno-
humeral joint. While the patient had full active range
of motion of the glenohumeral joint, her symptoms
occurred in both UE during passive range of motion
at 90° of shoulder flexion and 90° of shoulder abduc-
tion. No symptoms occurred during passive shoulder
extension or horizontal abduction. With passive hori-
zontal abduction, the medial end of the clavicles sub-
luxed anteriorly when passing through the plane of
scaption and then reduced with passive horizontal
adduction. During active range of motion, at 90° of
shoulder abduction the patient had symptoms of
numbness, tingling, and achy pain occurring on the
palmer and dorsal aspects of both the hands. These
symptoms initially occurred distally but began spread-
ing proximally as the position was held for longer
periods of time. At 90° of shoulder flexion, symptoms
of numbness, tingling, and achy pain only occurred in
the median nerve distribution bilaterally.
Manual muscle strength testing of various UE
muscles, including scapular muscles, revealed gener-
alized weakness throughout both UE secondary to
self-limiting in response to fear of reproducing the
symptoms (Table 1).
Joint play was manually graded on a 0–6 scale with 0
= anklyosed, 3 = normal, and 6 = unstable (Kalten-
born, 2002). Both SC joints received a grade of 5 (con-
siderable increase) indicating hypermobility during
posterior and inferior glides. Hypomobility was revealed
and a grade of 1 (considerable decrease) was given to
both first ribs (anterior, inferior, and posterior), both
acromioclavicular (AC) joints, and to T3–T4 in
anterior/superior motion during flexion, and posterior/
inferior motion during extension and bilateral rotation.
The position of the medial end of the clavicle in
relation to the anterior sternum was measured with
the patient in sitting and supine position with a measur-
ing tape and a clipboard. This measurement technique
Session 12 Visit 13 (discharge)
3/5 3/5
4/5 4/5
L 3 + 5; R 3 + /5 L 3 + /5; R 3 + /5
L 5/5; R 5/5 L 4/5; R 5/5
L 4/5; R 5/5 L 4/5; R 4/5
L 5/5; R 5/5 L 5/5; R 5/5
L 4/5; R 4/5 L 5/5; R 5/5
L 4/5; R 4/5 L 4/5; R 4/5
L 4/5; R 4/5 L 4/5; R 4/5
L 3/5; R 3/5 L 3/5; R 3/5
Copyright © Informa Healthcare USA, Inc.
 Physiotherapy Theory and Practice 565

was created in an attempt to objectively measure the ob-
served differences. No other methods to measure the
difference between the anterior surfaces of the clavicle
and sternum are known to us. The clipboard was
aligned in the sagittal plane with the SC joint and a
pen was used to place a mark on the clipboard to
measure the distance from the anterior surface of the
sternum to the anterior surface of the medial clavicle.
The distance was then measured, in millimeters, with
a measuring tape. In supine position, superior subluxa-
tion was measured using the same method (Table 2).
Onset and resolution of symptoms
The times to onset of symptoms were measured with
the patient actively maintaining her upper extremities
in 90o of shoulder flexion and 90o of shoulder abduc-
tion (Table 3). The time to resolution of symptoms
was measured when the UE was returned to a
neutral position (arms by side of trunk). Throughout
the course of the treatment, as the time to onset in-
creased, measurements in full shoulder flexion were
added (Table 4).

TABLE 2 SC joint subluxation measurements during the course of treatment.

Measurement

Direction and position Session #2 Session #6 Session #12 Session #13 (discharge)

Anterior subluxation in sitting with L: 5 mm; R: 6 mm R: 4 mm; L: 1.5 mm L: 4 mm; R: 3 mm L: 4 mm; R: 4 mm

arms down by side
Anterior subluxation in supine with L: 0 mm; R: 4 mm R: 0 mm; L: 0 mm L: 0 mm; R: 0 mm L: 0 mm; R: 2 mm
arms down by side
Superior subluxation in supine with L: 6 mm; R: 8 mm R: 10 mm; L: 8 mm L: 9 mm; R: 8 mm L: 10 mm; R: 8 mm
arms down by side
Anterior subluxation in supine with L: 8 mm; R: 10 mm R: 4 mm; L: 3 mm L: 2.5 mm; R: 3 mm L: 4 mm; R: 4 mm
arms abducted to 90°

L, left; R, right; mm, millimeters.

TABLE 3 Time of onset and resolution of symptoms at 90° shoulder flexion and 90° shoulder abduction.

Session #
Position of 13
arms Session # 4 Session # 5 Session # 7 Session # 8 Session # 10 Session # 11 Session # 12 (discharge)

90 o shoulder flexion
Onset B UE = 5′′ B UE = 9′′ B UE = 20′′ ; B UE L UE (-); R 5th B UE (-); B UE (-); B UE (-);
muscle minimal digit = 40′′ ; held 90′′ ; held 90′′ ; held 90′′
fatigue = 10′′ tingling held 1′ mild mild
= 15′′ ; shoulder shoulder
muscle muscle muscle
pain = 45′′ fatigue fatigue
Resolution B UE = 2′′ B UE = 10′′ B UE = 5′′ B UE = 13′′ R UE = 5′′
90 o of shoulder abduction
Onset L UE = 5′′ ; R UE = 9′′ ; B UE = 35′′ ; Minimal L UE (-); R 5th B UE (-); B UE (-); B UE (-);
R UE (-) L UE muscle tingling in digit = 40′′ ; held 90′′ ; held 90′′ ; held 90′′
′′ ′
= 14 weakness and B UE held 1 mild mild
fatigue = 10′′ = 20′′ ; shoulder shoulder
muscle muscle muscle
pain in fatigue fatigue
B UE
= 45′′
Resolution L UE = 5′′ B UE = 14′′ B UE = 10′′ B UE = 15′′ R 5th
digit = 8′′

B, Bilateral; L, left; R, right; UE, upper extremity; (-), negative for symptoms; ′′ , seconds; ′ , minutes.

Physiotherapy Theory and Practice

566 Nichols and Seiger

TABLE 4 Time of onset and resolution (in sec) of symptoms at full shoulder flexion.

Position of Session # 13
arms Session # 8 Session # 9 Session # 10 Session # 11 Session # 12 (discharge)

Full shoulder flexion

Onset Tingling and Without orthosis: R 2nd to 4th Mild tingling L B UE (-); held B UE (-);
coldness in tingling; R UE = 36′′ , digits =30′′ ; palm = 35′′ ; 90′′ ; mild held 90′′
B UE = 15′′ ; L UE = 30′′ ; with L 3rd to 4th R UE (-); position shoulder
muscle pain orthosis: R UE (-), digits = 50′′ ; maintained for muscle
in B UE L UE N/T; held 1′ held 1′ 90′′ ; slight muscle fatigue
= 50′′ fatigue
Resolution B UE = 20′′ Tingling R UE = 36′′ , B digits = 10′′ L UE = 4′′
L UE = 30′′

B, Bilateral; L, left; R, right; UE, upper extremity; (-), negative for symptoms; ′′ , seconds; ′ , minutes.

TABLE 5 Psychometric properties of special tests (Gulick, 2009).

Neural tension tests

Cervical Median
compression Cervical distraction nerve Ulnar nerve Radial nerve

Sensitivity 30–60% 40–44% 94% Not reported 97%

Specificity 74–100% 90–100% 22% Not reported 33%
Thoracic outlet syndrome provocation tests
Adson’s test Wright’s Military Brace Allen’s test Adson’s Adson’s
hyperabduction (costoclavicular) test + Wright’s + Wright’s
test (pain) (pulse)
Sensitivity Not reported Pulse = 70%; Not reported Not reported 79% 54%
pain = 90%
Specificity 74–89% Pulse = 53%; Not reported Not reported 76% 94%
pain = 29%

Palpation obliterated radial pulse. The costoclavicular (Military

In prone and sitting position, palpation of the cervical
and capital extensors revealed tightness, suggesting
hypertonicity and overuse.
Special tests
Cervical compression and cervical distraction were
negative bilaterally for a nerve root compression.
Radial, medial, and ulnar nerve tension tests were
negative bilaterally for a peripheral nerve compression.
The TOS special tests performed were: the Adson’s
maneuver; Allen’s test; Wright’s hyperabduction test;
and costoclavicular (Military Brace) test (Gulick,
2009). The Adson’s maneuver was positive bilaterally
with a reproduction of symptoms and a diminished
radial pulse. The Allen’s test was positive bilaterally
with a reproduction of symptoms and an obliterated
radial pulse. Wright’s hyperabduction test was positive
bilaterally with a reproduction of symptoms and an
Brace) test was positive bilaterally with a reproduction
of symptoms, and the left pulse was obliterated and
the right pulse was diminished. All of these tests indi-
cated the presence of TOS. However, the Adson’s test
was negative for TOS symptoms when the test was
repeated while a posterior glide was maintained on
the medial clavicle at the SC joint. The Roos’ test
was not performed due to the rapid onset of symptoms
during the other tests. The psychometric properties of
the special tests are listed in Table 5.
DIAGNOSIS AND PROGNOSIS
Because of the patient’s age and unknown etiology, she
was referred to her pediatrician for a CT scan with con-
comitant angiography to rule out a possible epiphyseal
plate disruption at both clavicles or other vascular in-
volvement. The results from the CT scan were negative
for abnormal findings in the cervical spine, thoracic
spine, and SC joints. The results from the concomitant

Copyright © Informa Healthcare USA, Inc.


angiography revealed mild impingement of the
subclavian arteries during full shoulder flexion.
The description and nature of the patient’s symp-
toms were more consistent with a posterior subluxa-
tion. However, the relief of symptoms during the
Adson’s test with a sustained posterior glide on the
medical clavicle was indicative of an anterior subluxa-
tion. These examination findings suggested bilateral
TOS secondary to an idiopathic anterior subluxation
of bilateral SC joints resulting in increased com-
pression on the subclavian and vertebral arteries,
which may be related to her symptoms of headaches,
vision loss, numbness, and coldness during functional
activities such as overhead and reaching activities.
The patient was classified into the practice pattern
4D: Impaired joint mobility, motor function, muscle
performance, and range of motion associated with
connective tissue dysfunction outlined by the Guide
to Physical Therapist Practice (American Physical
Therapy Association, 2003). The physical therapy
diagnosis was that the patient was unable to perform
overhead and reaching activities associated with
numbness, tingling, and coldness in both UEs sec-
ondary to a possible idiopathic anterior subluxation
of both SC joints. Her prognosis was fair to good
due to the difficulty in stabilizing the SC joints due
to a lack of muscular attachments to pull the clavicular
bone posteriorly. Additionally, there are no muscles
around the SC joints that the patient could strengthen
to stabilize the joints. However, the patient was young,
motivated, had good family support, and was active in
sports prior to the onset of her symptoms.
The specific goals set for this patient included: 1)
increased strength of all shoulder MMTs to grossly
4/5 in 6 weeks; 2) ability to play her acoustic guitar
with it positioned on her lap with minimal-to-no
numbness, tingling, or pain in bilateral upper extremi-
ties via patient report in 6 weeks; 3) independence and
adherence to a HEP consisting of shoulder strength-
ening and stabilization exercises in 3 weeks; and 4)
perform simulated boxing on the Wii for 30 minutes
with minimal-to-no numbness, tingling, or pain in
bilateral upper extremities in 6 weeks. The patient’s
expected long-term outcome was that she would be
able to return to her prior level of function, be inde-
pendent in all ADLs, and participate in leisure activi-
ties without limitation secondary to headaches, vision
loss, or numbness, tingling, and pain in bilateral upper
extremities.
INTERVENTION
The patient received physical therapy one to two
sessions per week, with each session lasting
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 567
approximately 60 min. Physical therapy interventions
consisted of therapeutic and functional exercises,
manual therapy techniques, and the experimental
use of two orthoses. Therapeutic exercises consisted
of shoulder and scapular resistance and stabilization
exercises to stabilize the SC joints and improve UE
muscle performance (Kisner and Colby, 2007). Func-
tional exercises consisted of simulated boxing on the
Nintendo Wii, as well as actual boxing sequences
against the evaluator that were incorporated to evalu-
ate the patient’s ability and readiness to participate
in boxing and other sports. Manual therapy included
soft tissue massage and joint mobilizations to the
AC joint and first rib. These joint mobilizations
were applied to improve joint hypomobility, and to
indirectly improve the stability of the SJ joints to
decrease TOS symptoms (Wise and Gulick, 2009).
See Table 6 for a description of treatment for each
physical therapy session.
Two types of orthoses were tried without success.
The first orthosis was a reverse figure-8 brace and it
was used to provide mobilization and promote stabil-
ization of the SC joints. After multiple fitting attempts,
this orthosis was discarded due to its inability to
provide adequate support to maintain a sustained pos-
terior glide to both SC joints. The second orthosis was
a custom-made, experimental orthosis designed by a
local orthotist. This orthosis was a modified truss
and was individualized to the patient with the same
intent as the first orthosis. This custom-made orthosis
demonstrated significant potential by providing
enough posterior force on the medial clavicle to
reduce the onset of symptoms in both UEs during
reaching overhead; however, it was not comfortable
or practical for the patient to wear. The patient was
given the orthosis for 2 weeks, but she was only
willing to wear it 50% of the time because of difficulty
donning/doffing and the inability to use her UEs while
wearing the orthosis. The patient reported that when
the straps were hooked to her belt loops, she was
unable to move her trunk and perform her ADLs,
but when the straps were not hooked to her belt
loops, the orthosis would slip off her shoulders easily.
OUTCOMES
The patient was discharged after 12 visits over 16
weeks. After 16 weeks of treatment, the patient was
put on hold for 10 weeks to determine if the home
exercise program would maintain her current status.
When the patient returned for visit 13, after 10
weeks, she did not have return of her symptoms and
was able to maintain her home exercise program. At
this visit, she was discharged because: 1) she achieved
568 Nichols and Seiger

TABLE 6 Descriptions of physical therapy interventions for each treatment session.

Initial Manual therapy

evaluation Self-mobilization: posterior glide, medial end of clavicle during overhead movements
Patient education
Examination findings, anatomy and importance of sternoclavicular (SC) joints, correct posture
Session # 2 Therapeutic/functional exercises
Cervical stabilization exercises, supine
Patient education
Referred to pediatrician for CT scan
Session # 3 Therapeutic/functional exercises
Shoulder flexion (flex), extension (ext), external rotation (ER), internal rotation (IR), horizontal adduction (add),
supine, light resistance band, 1 × 10 each
Patient education
Home exercise program (HEP)
Session # 4 Therapeutic/functional exercises
Alternating unilateral superman against gravity, prone, 1 x 10, hold 5 sec
Partial airplane against gravity, prone, 1 × 10, hold 5 sec
Middle rows, sitting on 65 cm ball, 2 × 10, medium resistance band
Body blade exercises, standing: arm by side, arm in front of body, and arm behind body, 30 sec, bilateral
Manual therapy
First rib: sitting, bilateral, Grade III oscillations, inferior glide
Patient education
HEP
Session # 5 Therapeutic/functional exercises
Shoulder flex, ext, ER, IR: 1 × 10 each, light resistance band
Upper extremity PNF D2 flex and ext, 1 × 10 each, light resistance band
Alternating unilateral superman against gravity, prone, 1 × 10, hold 5 sec
Airplane against gravity, prone, 1 × 5, hold 5 sec
Scapular adduction, sitting, 1 × 10, hold 5 sec
Sternocleidomastoid contraction, supine, 1 × 10
Cervical extensor stretch, sitting, 1 × 30 sec
Levator scapulae stretch, sitting, 1 × 30 sec
Manual therapy
Acromioclavicular joint: bilateral, Grade III oscillations, inferior and anterior/inferior glides, Grade IV sustained
Patient education
HEP
Session # 6 Orthotic fitting
Reverse figure-8 brace fitted to apply posterior force to both SC joints
Figure-8 brace fitted to promote proper posture
Across-the-heart Ace bandage wrap to apply posterior force to both SC joints
Patient education
HEP
Session # 7 Manual therapy
Lateral telescoping to clavicle and scapular bilateral × 10 min, supine
PPIVMs: cervical and upper thoracic spine
Spring testing: thoracic spine
Patient education
Education on hydration, progression of HEP into sitting and standing positions
Session # 8 Therapeutic/Functional exercises (orthosis not worn during exercises)
Body blade exercises, standing: arm down by side in front of body, to side of body, and behind body, 30 sec each
Ball on wall stabilization, 90° flexion, 2 × 10 of up/down and side-to-side
Wii boxing × 15 min, no symptoms in both hands and arms
Manual therapy
First rib mobilizations B: Grade III and IV oscillations, inferior glides
Patient education
Orthosis fitting × 20 min: attempted to apply a posterior glide to both SC joints
Session # 9 Orthosis fitting
Custom fit for orthosis
Wear orthosis 1 hour/day, then slowly increase time as her body adapts to wearing it
Wear the orthosis during the day and during aggravating activities
(Continued )

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 Physiotherapy Theory and Practice 569

TABLE 6 (Continued)
Session # 10 Therapeutic/functional exercises
Shoulder flex, prone on 65 cm ball, 2 × 12, no resistance
Shoulder horizontal abduction, prone on 65 cm ball, 2 × 12, no resistance
Wall pushups, 65 × cm ball, 2 × 12
High to low rows, medium resistance band, 2 × 12
Middle rows at 90° abduction, medium resistance band, 2 × 12
Body blade exercises in standing: 90° flexion, 90° abduction with blade horizontal, 90° abduction with blade vertical,
and full flexion, 30 sec each
Patient education
Exercises to be performed upright instead of in supine
How to alter her orthosis to improve her ability to move while wearing, including attaching one front strap and the
opposite back strap
Session # 11 Therapeutic/functional exercises
Shoulder flex, prone on 65 cm ball, 2 × 12, no resistance
Wall pushups in standing, 65 cm ball, 2 × 12
Ball on wall stabilization in standing, 3 lb ball, 90° flexion: up/down, side-to-side, clockwise circles, and
counterclockwise circles, 30 sec each
Body blade exercises, in standing, upper extremity PNF D2 flexion/extension, ×2 B, to fatigue
Stick wrestling, ×3, kneeling
Patient education
Recommended not to participate in boxing
Given option of kickboxing, because increased use of legs
Session # 12 Therapeutic/functional exercises
Arm Bike × 5 min, at 2.5 resistance level
Boxing, with boxing gloves, standing, 30–60 sec each: R J + L SH; L J + R SH; R SH + L SH + SQ; L SH + R
SH + SQ; R SH + L UC; L SH + R UC; L J + R SH + R K; R J + L SH + L K; R UC + L UC
R = right, L = left, J = jab, SH = straight hook, SQ = squat, UC = upper-cut, K = kick
Patient education
Shoulder stabilization exercises and the HEP during the next 8–10 weeks
Recommended no boxing
Session # 13 Patient education
Continue performing HEP every day to prevent a recurrence of symptoms
Participating in sports may contribute to recurrence of symptoms

all of her personal and physical therapy goals; 2) she
verbally expressed the understanding of the impor-
tance of performing her HEP every day for the rest
of her life; and 3) she verbally expressed an under-
standing of the risks of participating in sports.
Subjective report
Upper Extremity Functional Index
At discharge, the patient had improved her score on
the Upper Extremity Functional Index from a 70/80
to an 80/80. This 10-point change is greater than the
9-point minimal detectable change needed to indicate
improvement in the patient’s perceived level of disabil-
ity (Stratford, Binkley, and Stratford, 2001).

At discharge, the patient self-reported a 95% improve- Mobility and strength

ment in her headaches, vision loss, and numbness,
tingling and coldness in both UEs compared to pre-
intervention symptoms. The patient stated that her
vision loss only occurred when she was sick and dehy-
drated and her headaches were infrequent and only
occurred when she had a lack of sleep or was dehy-
drated. The patient was independent and symptom
free in ADLs and recreational activities. She no
longer experienced numbness, tingling, and coldness
in both hands during overhead activities, including
volleyball and boxing, and was able to participate in
volleyball without limitation secondary to vision loss
or headaches.
Cervical range of motion was within normal limits and
pain free in all directions. She also experienced an
overall increase in upper extremity muscle perform-
ance and strength as measured via manual muscle
testing (Table 1). No significant changes were noted
in the position of the medial end of the clavicle in
relation to the anterior sternum (Table 2).
Onset and resolution of symptoms
The patient experienced an overall decrease in the fre-
quency and severity of the numbness, tingling, and

Physiotherapy Theory and Practice

570 Nichols and Seiger
coldness in both UEs and she maintained a static pos-
ition of 90o of shoulder flexion, 90o of shoulder abduc-
tion, and full shoulder flexion without the onset of
symptoms (Tables 3 and 4).
Special tests
The patient experienced no reproduction of symptoms
with any of the TOS tests (Gulick, 2009). However, she
continued to experience a diminished left radial pulse
with the Allen’s test and an obliterated left and dimin-
ished right radial pulse during Wright’s hyperabduc-
tion test. These vascular findings indicated that the
patient continued to be at risk to a recurrence of symp-
toms in both UEs; thus, she was educated to continue
performing her home exercise program in order to
prevent a recurrence of symptoms.
DISCUSSION
Over the course of the treatment, the patient reported
reductions in the frequency of vision loss, the fre-
quency and severity of headaches, and the frequency
and severity of numbness, tingling, and pain in both
hands and UEs. The patient also experienced
improvements in overall upper extremity strength.
Factors contributing to this outcome included the
patient’s adherence to the home exercise program of
shoulder resistance and stabilization exercises, her
willingness to participate in all recommended activi-
ties in the clinic, and her motivation and desire to par-
ticipate in sports.
TOS is a possible complication of a posterior SC
joint subluxation but has only been associated with
an anterior SC joint subluxation after surgical fixation
of the medial end of the clavicle. No evidence in the
literature was found to support conservative treatment
for individuals with TOS secondary to SC joint sub-
luxations. Research indicates that anterior SC joint
subluxations are successfully managed with conserva-
tive treatment including oral analgesia, topical ice,
immobilization in a sling, closed reduction under
anesthesia, and physical therapy and modification of
activity (Robinson, Jenkins, Markham, and Beggs,
2008). A posterior SC joint subluxation decreases
the space in the thoracic outlet region resulting in
increased compression on the neurovascular struc-
tures, causing TOS symptoms. An anterior SC joint
subluxation increases the space in the thoracic outlet
region resulting in decreased compression on the neu-
rovascular structures. The patient in this case report,
however, experienced TOS symptoms as a result of a
possible anterior SC joint subluxation since the
symptoms immediately resolved with a sustained pos-
terior glide to the clavicle at the SC joint. The reason
for why an anterior subluxation of the medial clavicle
may result in TOS symptoms is unknown; but it is
hypothesized that a congenital abnormality was the
cause of these symptoms (Laulan et al, 2011).
Because the patient had pectus carinatum, it is poss-
ible that the sternal portion of the SC joint matured
at a different rate than the clavicular portion of the
SC joint. It is also possible that fibrous abnormalities
were present in the fascia and/or muscles. Thus, as
the medial end of the clavicle subluxed anteriorly,
increased tension on the fascia surrounding the indi-
vidual neurovascular structures within the thoracic
outlet increased compression on these neurovascular
structures resulting in the symptoms of TOS.
This case report is not generalizable, but it does
provide a good foundation for further research. The
method used to measure the degree of SC joint sub-
luxation was a clinical attempt to quantify the SC
joint position and movement, but there is no research
to support this measurement. In addition, the initial
measurements were performed with two evaluators
while all other measurements were performed with
only one evaluator. This could contribute to the differ-
ences in initial and discharge measurements.
Both of the orthoses tried for this patient were
unsuccessful. The first orthosis, a reverse figure-8
orthosis, was discarded due to its inability to provide
adequate posterior support to both SC joints. The
experimental orthosis, designed specifically for the
patient, showed significant potential by providing
enough posterior force to reduce the onset of symp-
toms in upper extremities; however, it was not comfor-
table or practical for the patient and, therefore, was not
consistently used.
Future research is needed to: 1) determine a reliable
and valid way to measure the position of the medial end
of the clavicle in relation to the anterior sternum; 2)
determine a reliable and valid way to measure the
amount of actual movement at the SC joint; 3)
develop an orthosis that provides sufficient support
for the SC joint while still being practical and comforta-
ble for the patient; and 4) identify specific exercises that
are best for stabilizing the SC joint.
CONCLUSION
This case reports suggests that an idiopathic anterior
subluxation of the SC joint could be a possible cause
for TOS and may need to be ruled out during exam-
ination of patients with TOS. The successful out-
comes in this case report support the use of PT
intervention for individuals with bilateral TOS
Copyright © Informa Healthcare USA, Inc.

secondary to bilateral anterior SC joint subluxation.
For this patient, PT intervention improved quality of
life, functional ability, participation in sports, and
social life. Although the outcomes of this case report
cannot be generalized, it does provide evidence that
SC joint dysfunction should be considered as a poss-
ible cause of TOS and should be screened during
the initial examination.
Declaration of interest: The authors report no
conflicts of interest.
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