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SUBCLAVIAN ARTERY AND VEIN

The subclavian artery feeds oxygenated blood to all tissues of the upper extremity; the subclavian vein drains deoxygenated blood from all tissues of the upper extremity.

While the subclavian artery can be entrapped in all three TOS impingement sites, the subclavian vein does not run between the anterior and middle scalenes, so it cannot be involved in anterior scalene syndrome. Compression of the subclavian vessels results in altered blood flow in the upper extremity. This usually manifests in color changes such as blanching (a pale or whitish appearance) or cyanosis (bluish/purplish appearance) of the skin.

Both of these result from a loss of blood supply to the tissues. Even though TOS brachial plexus nerve impingement is more common and usually more serious than TOS vascular impingement, subclavian artery impingement is particularly important because therapists use impingement of the subclavian artery to assess TOS.

IMPORTANCE OF TOS ASSESSMENT

Because symptoms of TOS can be located anywhere within the upper extremity, TOS may be misdiagnosed in clients by physicians and other qualified health care professionals. Mistakenly, clients are often told that they have a pathologic condition of a cervical disc or carpal tunnel syndrome because these conditions also cause nerve impingement with sensory/motor symptoms in the upper extremity. Given the possibly serious recourse to surgery for these other conditions, accurate assessment of TOS in our clients is of paramount importance. Another important reason to accurately assess TOS in our clients is that all three types of TOS respond so well to massage and bodywork.

METHOD OF TOS ASSESSMENT

With all three types of TOS, you can begin by assessing the strength of your clients radial pulse when he is relaxed and in a neutral position (Figure 3). The client is then passively moved or asked to move actively into a particular position; the strength of the clients radial pulse is assessed again. These assessment procedures for TOS follow logically from the mechanism of the type of impingement in each of the three types.

Figure 3 illustrates assessment of the strength of the clients radial pulse when the client is relaxed and in a neutral position. This is done at the beginning of the assessment procedure for each of the three TOS conditions.

For example, anterior scalene syndrome causes an impingement due to tight anterior and middle scalene muscles. Therefore, the assessment procedure is to pull these muscles taut by stretching them. This is accomplished by asking the client to do the opposite actions of what the scalenes would do. Because these muscles do flexion, contralateral (opposite sided) rotation, and ipsilateral (same sided) lateral flexion of the neck at the spinal joints, if we ask the client to do extension, ipsilateral rotation, and contralateral lateral flexion, the scalenes will be stretched taut (Figure 4). If they were tight to begin with, when they are stretched and pulled taut by this procedure, they would further compress the brachial plexus and subclavian artery.

Figure 4 illustrates Adsons test for anterior scalene syndrome, one of the three types of TOS. The client is asked to ipsilaterally rotate, contralaterally laterally flex, and extend his neck at the spinal joints, while the radial pulse is palpated. Decrease in strength of the radial pulse is positive for anterior scalene syndrome.

Objectively, this impingement is assessed by palpating for a decrease in strength of the radial pulse at the wrist. This would indicate impingement of the subclavian artery and is a positive test result for anterior scalene syndrome. This procedure is called Adsons test. The importance of this assessment procedure is that if the subclavian artery is being impinged, we can assume that the brachial plexus of nerves also is being impinged.

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