Thoracic outlet syndrome surgery - cervical rib and scalenes excised

Ed Thompson

Mentorship Member
Nov 7, 2020

I have a 28 year old patient who I am working with post operatively.

She is making progress albeit slow, I just want to make sure I'm not missing anything!

Patient history:
  • She is a keen runner, has a busy desk job which requires long hours at the desk (until 7-8pm sometimes), very slim, tall and 6/9 on beighton score
  • I saw her initially for right sided cervical radiculopathy symptoms in February 2021 which seemed to be more vascular and I referred to a consultant who confirmed that she had neurogenic and vascular thoracic outlet syndrome due to a cervical rib.
  • Her right scalenes and cervical rib were removed in March 2021
  • She started physio with me about 1 month post-op as the surgeon wanted her to rest.
  • She initially had lots of pain / sensitivity around her wound site and problems with fatigue after any prolonged sitting or activity

Fast forward to now these are her main symptoms:
  • the area of her scalenes gets really stiff (hard / goes into spasm) after sitting at the desk all day and gets to a 5/10 until she lays down and is able to relax
  • any prolonged use of her right arm (was holding a gun in an arcade and her arm became fatigued after 30 seconds)
Objective findings:

  • Triceps, biceps and wrist flexors break during all coordinative testing for the upper limb and her serratus anterior and there is a lot of shaking
  • Active range of motion into left side flexion is very tight and bordering on painful and is otherwise full
  • Shoulder active range of motion is full and pain free
Treatment so far:

  • Graded exposure programme to all 4s
  • Strength work for her deltoids and rhomboids
  • Deep neck flexor strengthening
  • Coaching on sitting / using the back rest / slouching / breathing work

My questions are:

Should stretches be introduced to improve the mobility of her scalenes - I am normally against them in general but think this may help
Should I continue going down a strengthening route with her as it is seems an endurance issue, her coordinative testing is improving but has taken time to improve
Has anyone who has treated this before found that progress is this slow and what can she ideally expect to get back?
How do I get it so her scalenes stop going into spasm - have tried isometrics, breathing, relaxed / slouched sitting, heat
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