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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 subcoracoid space. Which of the following activities would MOST likely exacerbate the patient’s symptoms?

1. Reaching overhead to change a light bulb
2. Reaching over to wash the left armpit
3. Looking upward to shave the neck 
4. Looking downward while reading a book

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. My name is Scott Giles and I will be your host for today’s journey.

Ready? Let’s go!

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 subcoracoid space. Which of the following activities would MOST likely exacerbate the patient’s symptoms?

1. Reaching overhead to change a light bulb
2. Reaching over to wash the left armpit
3. Looking upward to shave the neck 
4. Looking downward while reading a book

Thoracic Outlet Syndrome
Thoracic outlet syndrome 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. Compression in the subcoracoid space typically occurs with shoulder elevation, especially if external rotation is also included.

Let’s explore each of the options:
Option 1 - Reaching overhead to change a light bulb
Reaching overhead to change a light bulb would require full active elevation of the shoulder. 

Elevation of the shoulder can exacerbate thoracic outlet syndrome symptoms when the source of the compression is occurring at the subcoracoid space. During full elevation of the shoulder, the coracoid acts as a fulcrum, where the neurovascular structures are forced to change direction.

Option 2 - Reaching over to wash the left armpit
Reaching over to wash the left armpit would require active horizontal adduction of the shoulder.

Subacromial Impingement
Though this type of cross-body movement could provoke symptoms associated with subacromial impingement, it would not exacerbate symptoms associated with thoracic outlet syndrome. Thoracic outlet syndrome due to compression in the subcoracoid space is typically aggravated with movements that require full shoulder elevation.

Option 3 - 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 thoracic outlet syndrome symptoms when the source of the compression is occurring at the interscalene triangle. Cervical extension would not cause significant movement to occur in the subcoracoid space.

Option 4 - Looking downward while reading a book
Looking downward while reading a book would require active cervical flexion. 

Movements of the cervical spine are more likely to cause thoracic outlet syndrome symptoms when the source of the compression is occurring at the interscalene triangle. Cervical flexion would not cause significant movement to occur at the subcoracoid space.

The correct answer is Option 1

Let’s explore the all student data:
50% of students selected Option 1, Reaching overhead to change a light bulb, the correct response
30% of students selected Option 2, Reaching over to wash the left armpit
15% of students selected Option 3, Looking upward to shave the neck
5% of students selected Option 4, Looking downward while reading a book

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 and A podcast! See you next week!