A patient is referred to physical therapy with a diagnosis of right thoracic outlet syndrome. The physical therapist identifies that the patient's symptoms are being caused by entrapment at the costoclavicular space. Which of the following activities would MOST likely exacerbate the patient's symptoms?

1. Reaching overhead into a high cupboard
2. Carrying a heavy bag in the right arm
3. Looking over the left shoulder while driving
4. Looking upward to shave the neck

Transcript

Welcome back to the Scorebuilders' Question and Answer Podcast! This podcast provides members of the Scorebuilders' team with the opportunity to explore challenging multiple-choice examination questions with students actively preparing for the licensing examination.

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A patient is referred to physical therapy with a diagnosis of right thoracic outlet syndrome. The physical therapist identifies that the patient's symptoms are being caused by entrapment at the costoclavicular space. Which of the following activities would MOST likely exacerbate the patient's symptoms?

1. Reaching overhead into a high cupboard
2. Carrying a heavy bag in the right arm
3. Looking over the left shoulder while driving
4. Looking upward to shave the neck

Thoracic Outlet Syndrome

Thoracic outlet syndrome, or TOS, is a term used to describe a group of disorders that presents with symptoms secondary to neurovascular compression of fibers of the brachial plexus. There are several areas where neurovascular compression can occur, including the interscalene triangle, the costoclavicular space, and the subcoracoid space.

Thoracic outlet syndrome is not a one-size-fits-all diagnosis. The location of the compression matters enormously, because different positions and activities stress different spaces. The question is telling us exactly where the compression is occurring - the costoclavicular space - and asking us which activity would make it worse.

So what do we know about the costoclavicular space? It is the space between the clavicle and the first rib. Compression in this space typically occurs with clavicle depression or rib elevation - in other words, anything that narrows the gap between those two structures. Keep that in mind as we work through the options.

Let's explore each of the options:

Option 1 - Reaching overhead into a high cupboard

Reaching overhead into a high cupboard would require active shoulder flexion. Elevation of the shoulder can exacerbate TOS symptoms when the source of the compression is occurring at the subcoracoid space. Shoulder flexion would not cause significant movement to occur at the costoclavicular space and would therefore not be the cause of this patient's symptoms.

Think about what happens when you reach overhead - the shoulder elevates, the arm moves up, and the structures around the subcoracoid space are stressed. That's a different neighborhood entirely from the costoclavicular space. This activity would be more concerning for a patient with subcoracoid compression, not costoclavicular compression.

Option 2 - Carrying a heavy bag in the right arm

Carrying a heavy bag in the affected arm would cause the arm to be pulled downward, which would in turn cause scapular depression. Scapular depression is a movement that can exacerbate TOS symptoms when the source of the compression is occurring at the costoclavicular space.

Picture this - a heavy bag pulling the arm and shoulder girdle downward. The clavicle drops with the shoulder, narrowing the costoclavicular space and compressing the neurovascular structures passing through it. This is a perfect storm for a patient with costoclavicular compression.

Option 3 - Looking over the left shoulder while driving

Looking over the left shoulder while driving would require active cervical rotation. Movements of the cervical spine are more likely to cause TOS symptoms when the source of the compression is occurring at the interscalene triangle. Cervical rotation would not cause significant movement to occur at the costoclavicular space.

The interscalene triangle is bordered by the anterior and middle scalene muscles and the first rib. Cervical movements that alter scalene tension - like rotation or side bending - can compress structures within that triangle. But our patient's compression is at the costoclavicular space, so cervical rotation is not the culprit here.

Option 4 - Looking upward to shave the neck

Looking upward to shave the neck would require active cervical extension. Movements of the cervical spine are more likely to cause TOS symptoms when the source of the compression is occurring at the interscalene triangle. Cervical extension would not cause significant movement to occur at the costoclavicular space. 

Just like Option 3, this is a cervical spine movement that implicates the interscalene triangle rather than the costoclavicular space.

When we match each activity to the specific compression site identified in the question, only carrying a heavy bag produces the clavicle depression that narrows the costoclavicular space and exacerbates this patient's symptoms.

The correct answer is Option 2.

Let's explore the all student data:
35% of students selected Option 1 - Reaching overhead into a high cupboard
45% of students selected Option 2 - Carrying a heavy bag in the right arm - the correct response
10% of students selected Option 3 - Looking over the left shoulder while driving
10% of students selected Option 4 - Looking upward to shave the neck

System Classification
This question is a Musculoskeletal System question which represents approximately 27% of all exam items.

Content Outline Classification
This question is a Foundations for Evaluation, Differential Diagnosis, and Prognosis question which represents approximately 33% of all exam items.

Level Classification
This question is a Level 2 question since the question requires students to integrate numerous pieces of information or to apply knowledge in a given clinical scenario. Remediation of Level 2 questions occurs by increasing flexibility with academic content and by carefully analyzing decision making processes when answering applied examination questions.

Academic Focus Area
Looking to review related academic content? Check out pages 364-365 in PTEXAM: The Complete Study Guide.

Thanks for joining us on the Scorebuilders Q&A podcast! See you next week!