The condition known as thoracic outlet syndrome is not one thing but the name given to a collection of symptoms, all ascribed to problems with compression of blood vessels or nerves as they pass through the anatomical thoracic outlet. This structure is outlined by the first rib, the collar bone or clavicle and the neck scalene muscles, with the neurological and vascular structures passing through it to reach the axilla and travel into the arm. Diagnosis of these related conditions is difficult and there is little clarity or consensus about them.

The first and vital issue is the correct diagnosis of the injury and its severity as this will dictate the whole course of the treatment and indicate the speed of progression to be expected and the length of time taken until the injury is recovered. Physiotherapy is the main treatment course and the physiotherapist will judge the programme depending on the severity of the injury and how long it is since it has occurred. There are no reliable scientific guidelines for this kind of injury management and rehabilitation so the programme will need to be individually set and adjusted to suit the changing needs of the patient.

Up to the six week point after injury the remodelling phase can be said to occur and by this stage the physiotherapist will test the patient to see if they can contract the hamstring muscle against maximal resistance without pain or anxiety. The physio will then ask the patient to perform isotonic muscle contractions in the prone position with larger number of repetitions and lower weights initially, progressing to higher weights and fewer repetitions if no pain is experienced. It is advisable not to be too fast in increasing the weight and force applied to prevent a recurrent injury or a chronic strain.

One of the most frequent chronic diseases of children and the most common rheumatological condition in this group is juvenile rheumatoid arthritis. This is not one disorder but a group of interrelated disorders which all exhibit inflammatory changes in the joints. The triggering factors for these diseases have not been uncovered and it has proven hard to delineate one particular type of condition from another due to the complex genetic factors. While it is often called JRA, there is a move to standardise the naming of these diseases into juvenile idiopathic arthritis.

Multiple Sclerosis or MS is a disease of the central nervous system characterised by inflammation and demyelination, the gradual loss of the insulation material around the nerves known as myelin. Sclerosis is the term given to describe the thickened and scarred small lesions which occur in the nerve tracts. The disease is continually active and forms new lesions regularly leading to gradually increasing levels of disability. The most common form of MS is the relapsing and remitting kind, meaning there are periods of worsening followed by at least partial recoveries.

Benign MS is a term used to describe some patients’ presentations but appears mostly incorrect as almost all patients suffer a continual progression of their disability, in some cases without particular attacks. Truly benign episodes are those attacks which occur and then remit without repetition in the future, which is rare. It is vital to have a realistic viewpoint from the perspective of the doctors, relatives and patients so that the correct information can be given and the correct treatments followed. Patients report mental and physical tiredness which is different from the more typical tiredness of functional over effort or poor sleep.

The fewer joint affected type of arthritis (oligoarticular) is characterised by having four or fewer joints affected, with the larger joints more typically affected such as the knees and ankles. These children usually appear well even though they may limp on walking. If only one hip seems affected this is very unusual for this type of arthritis and a different condition such as Perthes disease should be suspected. If the joints, such as the knees, are affected over a long period then the large extensor muscles of the thighs can weaken and waste, with tight hamstrings leading the flexion contractures of the knees. If the legs are affected asymmetrically then the length of the legs can develop a discrepancy.