Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 22 - Neurological and Neuromuscular Disorder Medical Treatment Guidelines
Subchapter B - Thoracic Outlet Syndrome
Section I-2221 - Initial Diagnostic Procedures

Universal Citation: LA Admin Code I-2221

Current through Register Vol. 50, No. 9, September 20, 2024

A. The OWCA recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related TOS complaint are listed below.

1. History taking and physical examination (Hx and PE) are generally accepted, well-established and widely used procedures which establish the basis for diagnosis, and dictate all other diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. Neurogenic TOS will be described separately from vascular TOS, although some general symptoms may occasionally overlap. Vascular TOS usually requires emergent treatment as described in the surgical Section. Treatment for non-specific neurogenic TOS begins with jobsite alteration and therapy as described in Section F. and rarely requires surgical intervention. True neurogenic TOS may require early surgical intervention if there is significant weakness with corresponding EMG/NCV changes. The medical records should reasonably document the following.

a. History Taking. A careful history documenting exacerbating activities and positions which relieve symptoms is essential. Timing of the onset of symptoms is important. TOS has been associated with trauma and motor vehicle accidents. Avocational pursuits should also be specifically documented.

i. Symptoms Common to Neurogenic TOS. Neurological symptoms are usually intermittent in non-specific TOS. If symptoms are constant, consider other diagnoses such as true TOS or other brachial plexus injuries. Neck pain is often the first symptom with complaints within the first few days of injury. Occipital headaches may also occur early. Some patients experience coldness or color changes in the hands. Neurogenic symptoms include the following:

(a). forearm (frequently medial), or proximal upper extremity pain;

(b). numbness and paresthesia in arm, hand and fingers:

(i). fourth and fifth digits: most common pattern;

(ii). all five fingers: next most common pattern;

(iii). first, second and third digits: symptoms may occur, but one must rule out carpal tunnel syndrome;

(c). upper extremity weakness: arm and/or hand; "dropping things" may be a common complaint;

(d). exacerbating factor: arm elevation. Common complaints are trouble combing hair, putting on clothing, driving a car, or carrying objects with shoulder straps such as back packs; disturbed sleep, etc.

(i). Symptoms Common to Vascular TOS

[a]. Pain, coldness, pallor, digital ischemia and claudication in the forearm are signs of arterial compromise which is most frequently chronic and due to subclavian aneurysm or stenosis.

[b]. Swollen, cyanotic, and sometimes painful arm is indicative of a venous obstruction requiring immediate attention.

b. Occupational Relationship for Neurogenic and Vascular TOS. In many cases, trauma is the cause vascular or neurogenic TOS. Clavicular fractures, cervical strain (including whiplash), and other cases of cervical trauma injuries have been associated with TOS. Continual overhead lifting or motion may contribute as can static postures in which the shoulders droop and the head is inclined forward. Activities which cause over-developed scalene muscles such as weight-lifting and swimming may contribute. The Paget-Schroetter syndrome, or effort thrombosis of the subclavian vein, may occur in athletes or workers with repetitive overhead forceful motion and neck extension. Arterial thrombosis or symptoms from subclavian aneurysms or stenosis are usually not work-related. Both classic neurogenic TOS (usually due to a cervical or anomalous first rib) and vascular TOS due to arterial compromise from stenosis or aneurysm are rarely work-related conditions.

c. Physical Findings

i. Physical Examination Signs used to Diagnose Classic or Non-specific Neurogenic TOS. Both extremities should be examined to compare symptomatic and asymptomatic sides.

ii. Provocative maneuvers (listed below) must reproduce the symptoms of TOS to be considered positive:

(a). tenderness over scalene muscles in supraclavicular area;

(b). pressure in supraclavicular area elicits symptoms in arm/hand, or Tinel's sign over brachial plexus is positive. The supraclavicular pressure test is positive for paresthesia in approximately 15 percent of asymptomatic individuals;

(c). Elevated Arm Stress Test (EAST) is performed with the arms abducted and shoulders externally rotated to 90 degrees with elbows bent to 90 degrees for 3 minutes (some examiners use 60 seconds). The patient may also be asked to repetitively open and close fists. A positive test reproduces upper extremity symptoms. When this test is performed for 3 minutes in an asymptomatic population, approximately 35 percent experience paresthesia;

(d). some literature has suggested another provocative elevated arm stress test. The patient holds his arms over head for one minute with elbows extended, wrists in a neutral position, and forearm midway between supination and pronation. If symptoms are reproduced, the test is positive.

d. Posture related brachial tests:

i. head tilting: lateral flexion of the neck (ear to shoulder) causes radiating pain and paresthesia in the contralateral arm consistent with TOS.;

ii. Military posture or costoclavicular maneuver. Shoulders are depressed and pulled backward in an exaggerated position. Reproduction of symptoms is a positive test. Approximately 15 percent of asymptomatic individuals will report paresthesia with this test.

e. Neurological Examination: usually normal in non-specific TOS, but may be abnormal.

i. Sensory Exam: may show decreased sensation to light touch, pain, vibration, and/or temperature in lower brachial plexus distribution. The entire ring finger is usually involved. This contrasts with ulnar neuropathy, which usually involves only the ulnar side of the ring finger.

ii. Motor Exam: weakness and/or muscle atrophy in either upper or lower trunk distributions including, but not limited to, valid dynamometer readings indicative of relative weakness in the affected limb. In lower plexus injuries, the abductor pollicus brevis often demonstrates more involvement and atrophy than the intrinsic interosseous muscles.

(a). Physical exam findings for vascular TOS cases. Suspicion of vascular compromise should lead to confirmation using appropriate imaging procedures.

(i). Arterial cases usually demonstrate an absent radial pulse at rest, pale hand and often ischemic fingers.

(ii). Venous obstruction presents with visible or distended superficial veins on the effected signs involving the anterior axillary fold and chest wall. The arm is usually swollen and cyanotic.

iii. Physical Exam-other tests which are recommended and may indicate additional diagnostic considerations.

(a). Neck rotation may be restricted and can indicate the presence of additional pathology.

(b). Upper Limb Tension Test-this provocative test may be positive for cervical radiculopathy, brachial plexus pathology, or other peripheral nerve pathology. It is considered sensitive but non-specific. The test has several variations; however, they all consist of a series of systematic maneuvers performed on the upper quadrant to evaluate peripheral nerve function and pathology. Head tilting is one of the maneuvers included. Provocation of abnormal responses indicates neural tissue sensitization/irritation, and can include implication of specific peripheral nerve trunks. Performance and interpretation of this test requires specific training and experience. A negative response to the upper limb tension test makes the diagnosis of neurogenic TOS unlikely. If negative, investigate other diagnoses.

(c). Rotator cuff/acromioclavicular (AC) joint tenderness suggests rotator cuff, or biceps tendonitis or AC joint disease.

(d). Trapezius muscle, shoulder girdle muscles or paraspinal muscle tenderness suggests a myofascial component.

(e). Drooping shoulders secondary to nerve injuries can be present with TOS symptoms. If a spinal accessory, long thoracic or other nerve injury is identified, treatment should focus on therapy for the nerve injury in addition to conservative measures for TOS. Refer to the Shoulder Injury Medical Treatment Guidelines. Brachial Plexus and Shoulder Nerve Injuries.

(f). The following tests suggest carpal tunnel syndrome:

(i). carpal tunnel compression test;

(ii). flicking the wrist secondary to paresthesia;

(iii). Tinel's sign; and/or

(iv). Phalen's sign.

(g). Positive Tinel's sign at elbow (over ulnar groove) suggests ulnar nerve entrapment.

(h). Positive Tinel's sign over the pronator teres muscle suggests median nerve involvement. Positive Tinel's sign over the radial tunnel suggests radial nerve compression.

f. Cervical spine x-ray is a generally accepted, well-established procedure indicated to rule out cervical spine disease, fracture, cervical rib or rudimentary first rib when clinical findings suggest these diagnoses. Cervical spine x-rays should also be considered when there is an asymmetric diminished pulse in an arm that is symptomatic. X-rays are most useful when arterial TOS is suspected. The presence of a cervical rib does not confirm the diagnosis unless other clinical signs and symptoms are present, as many cervical ribs are asymptomatic. Therefore, routine roentgenographic evaluation of the cervical spine is frequently unnecessary early in the course of treatment for non-specific TOS.

g. Vascular Studies. Vascular laboratory studies, including duplex scanning, Doppler studies, standard and MR arteriography and venography are required for patients presenting with arterial or venous occlusion, as these patients may require immediate thrombolytic intervention. These studies are not indicated for neurogenic TOS.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.

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