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Treatment of Thoracic Outlet Syndrome: Where to Begin

presented by Ann Porretto-Loehrke

Accreditation Check:

Now that you’ve determined that your patient has disputed neurogenic thoracic outlet syndrome (TOS), what should be addressed first? This course will provide a step-by-step process for how to address your patient’s impairments at the 1st and 2nd ribs, scapular resting position and acromioclavicular, and sternoclavicular joints.

CHTs, when submitting this for recertification through HTCC, this course can be used for CAT B (hand therapy courses < 3 hours in length); however, if this course certificate is submitted with the following course certificates listed below (or any combination totaling 3 hours or more), they can be submitted under CAT A (hand therapy courses > 3 hours in length).

  • Identification & Evaluation of Thoracic Outlet Syndrome (2 hours)
  • Thoracic Outlet Syndrome: Assessing the Elevation Chain (1.25 hours)
  • Treatment of Thoracic Outlet Syndrome: Where to Begin (1.75 hours)
  • Treatment of Thoracic Outlet Syndrome: Addressing Shoulder and Upper Thoracic Limitations (1.5 hours)


  • Meet Your Instructor

    • Ann Porretto-Loehrke, PT, DPT, CHT, COMT, CMTPT

      Ann Porretto-Loehrke is a skilled clinician and dynamic instructor. She is the therapy manager of a large department at the Hand to Shoulder Center. Ann is a Certified Hand Therapist (CHT) and a Certified Orthopedic Manual Therapist (COMT) for treatment of the upper quadrant through the International Academy of Orthopedic Medicine (IAOM). She has extensive training in the evaluation and treatment of the upper quadrant. Ann completed a post-professional Doctorate in Physical Therapy (DPT) degree from Drexel University with a specialty in hand and upper quarter rehabilitation. Most recently, Ann has become certified in dry needling through Myopain Seminars, as a Certified Myofascial Trigger Point Therapist (CMTPT). She previously served as the Vice-Chair of the Examination committee for the Hand Therapy Certification Commission (HTCC). Ann also previously served as the Northeast District chair for the Wisconsin Physical Therapy Association from 2004 to 2008. She is a lead instructor who developed the Hand & Upper Extremity Track through IAOM, a set of six manual therapy courses designed specifically for hand and upper extremity specialists. Ann has presented at American Society of Hand Therapists (ASHT) annual conferences, Canadian Hand Conferences, Philadelphia meeting, and Teton Hand Conference.

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    Chapters & Learning Objectives

    Download Learning Objectives
    1. Joint-Specific Treatment to Address 1st & 2nd Rib Limitations

      1. Joint-Specific Treatment to Address 1st & 2nd Rib Limitations

      This chapter covers the manual therapy techniques to address limitations at the 1st and 2nd ribs. This is critical for TOS patients, as an elevated 1st rib can contribute to brachial plexus irritation at both the scalene triangle and costoclavicular space.

    2. Addressing Scapular Alignment & Dynamic Control

      2. Addressing Scapular Alignment & Dynamic Control

      Poor scapular alignment and limited mobility in the upper extremity elevation chain can contribute to TOS, especially with compressors. This chapter covers how to address poor resting scapular position and dynamic control with scapular taping techniques and therapeutic exercise.

    3. Joint-Specific Treatment to Address Limitations at the Acromioclavicular and Sternoclavicular Joints

      3. Joint-Specific Treatment to Address Limitations at the Acromioclavicular and Sternoclavicular Joints

      TOS patients who experience their symptoms with overhead motion can sometimes present with clavicular dysfunction. This chapter covers joint-specific techniques to address limitations at the sternoclavicular joint (SCJ) or acromioclavicular joint (ACJ).