A Prospective Evaluation of Duplex Ultrasound for Thoracic Outlet Syndrome in High-Performance Musicians Playing Bowed String Instruments

Abstract

Thoracic outlet syndrome (TOS) is a neurovascular condition involving the upper extremity, which is known to occur in individuals who perform chronic repetitive upper extremity activities. We prospectively evaluate the incidence of TOS in high-performance musicians who played bowed string musicians. Sixty-four high-performance string instrument musicians from orchestras and professional musical bands were included in the study. Fifty-two healthy volunteers formed an age-matched control group. Bilateral upper extremity duplex scanning for subclavian vessel compression was performed in all subjects. Provocative maneuvers including Elevated Arm Stress Test (EAST) and Upper Limb Tension Test (ULTT) were performed. Abnormal ultrasound finding is defined by greater than 50% subclavian vessel compression with arm abduction, diminished venous waveforms, or arterial photoplethysmography (PPG) tracing with arm abduction. Bowed string instruments performed by musicians in our study included violin (41%), viola (33%), and cello (27%). Positive EAST or ULTT test in the musician group and control group were 44%, and 3%, respectively (p = 0.03). Abnormal ultrasound scan with vascular compression was detected in 69% of musicians, in contrast to 15% of control subjects (p = 0.03). TOS is a common phenomenon among high-performance bowed string instrumentalists. Musicians who perform bowed string instruments should be aware of this condition and its associated musculoskeletal symptoms.

Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions

“…Although cases of thoracic outlet syndrome in musicians have been documented [ 15 ], until now it had not been rigorously studied. A recent paper in this journal [ 16 ] prospectively evaluated 64 high-performance string instrument musicians and 52 healthy age-matched controls. They found positive elevated arm stress test (EAST) or upper limb tension test (ULTT) in 44% of musicians compared with 3% in the control group.…”

Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations

“…Compression of the subclavian artery or vein is classified as vascular TOS (vTOS) [ 9 ]. The condition is caused by the presence of a cervical rib or bony growth near a nerve root in the neck [ 2 , 9 , 10 , 11 , 12 , 13 ]. This abnormality may alter the attachment site of the scalenes, which may further complicate vTOS [ 1 , 5 , 6 , 10 , 14 , 15 ].…”

“…Proper physical examination of the patient can help differentiate between the various forms of TOS, and other conditions that elicit similar symptoms of TOS (i.e., carpal tunnel syndrome or pectoralis minor syndrome) [ 17 , 19 , 20 ]. Approximately 90% of all TOS cases are diagnosed as nTOS [ 4 , 11 , 12 ]. The majority of vTOS cases are diagnosed as arterial vTOS [ 4 ].…”

“…The majority of vTOS cases are diagnosed as arterial vTOS [ 4 ]. Thoracic outlet syndrome is typically diagnosed in early adulthood (i.e., ages 20–40 years), and is more prevalent in those with the shoulder flexed for majority of the work day, have repeated trauma to the shoulder joint, and with those who exhibit abnormal posture, including positions required to play bowed instruments [ 11 , 15 ]. Repeated trauma to the head or neck, postural dysfunction, extended duration in compromising shoulder positions, pregnancy, edema, anatomical deviations, hypertrophied muscles (e.g., scalenes), boney growths, and muscle weakness are all theorized to be contributing factors to TOS [ 2 , 4 , 9 , 11 , 12 , 13 , 18 ].…”

The Art of Caring in the Treatment of Thoracic Outlet Syndrome

“…A unique report on high performance musicians who played bowed string instruments is presented by Adam and colleagues [ 16 ]. Sixty-four high performance musicians were evaluated and compared to 52 healthy volunteers with duplex scanning and provocative maneuvers.…”