Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a syndrome that involves compression of a nerve or blood vessel (brachial plexus, the subclavian artery, and, rarely, the subclavian vein) at the thoracic outlet (space between the neck, 1^st rib and collarbone).  It can affect one or more of the nerves that innervate the upper limb and/or blood vessels as they pass between the chest and upper extremity.  There are 3 main compression sites for this condition.  1) Compression on the nerve or blood vessels as they travel between two muscles in the neck (anterior and middle scalene)  2) Compression of the nerve or blood vessels as they pass between the collar bone and first rib and 3) Compression of the nerve or blood vessels between the pectoralis minor muscle and coracoid process.

Generally, there are three types of thoracic outlet syndrome. 1)Neurological  thoracic outlet syndrome. This form of thoracic outlet syndrome is characterized by compression of nerves that come from your spinal cord and control muscles and sensation in your shoulder, arm and hand. In the majority of thoracic outlet syndrome cases, the symptoms are neurogenic ~90%. 2) Vascular thoracic outlet syndrome. This type of thoracic outlet syndrome occurs when one or more of the veins or arteries under the collarbone are compressed.  3) Nonspecific-type thoracic outlet syndrome. This type is also called disputed thoracic outlet syndrome. People with nonspecific-type thoracic outlet syndrome have chronic pain in the area of the thoracic outlet that worsens with activity, but the specific cause of the pain can’t be determined.

Throbbing lump near your collarbone TOS affects mainly the upper limbs, with signs and symptoms manifesting in the arms and hands. Pain is usually present in the extremity and can be sharp, burning, or aching. It can involve only part of the hand (the ring and pinky finger), all of the hand, or the inside of the forearm and upper arm. Pain can also be in the side of the neck, the pectoral area below the clavicle, the armpit and/or the upper back. Patient’s may also have discoloration of the hands or complain that one hand is colder than the other.  Thoracic outlet syndrome symptoms can vary, depending on which structures are compressed. When nerves are compressed, signs and symptoms of NEUROLOGICAL thoracic outlet syndrome produce; Loss of muscle in the fleshy base of your thumb, numbness or tingling in your arm or fingers, pain or aches in your neck, shoulder or hand and a weakened grip.  Signs and symptoms of VASCULAR thoracic outlet syndrome can include: Discoloration of your hand (bluish color),  weak or no pulse in the affected arm , cold fingers, arm pain and swelling, possibly due to blood clots, fatigue after activity, numbness or tingling in your fingers, weakness of arm or neck

Proper diagnosis of thoracic outlet syndrome requires the expert attention of experienced specialists. Diagnosis may include a comprehensive clinical exam, including orthopedic and neurological exams, medical history and possibly imaging studies such as X-rays,  MRI and/or electrodiagnostic studies (EMG). Diagnosis is necessary to determine the cause of TOS, so the appropriate treatment plan, including a surgical option is considered. There is currently no single clinical sign that makes the diagnosis of TOS with any degree of certainty.

Common orthopedic tests used are the Adson’s test, the Costoclavicular Maneuver, and the “Hands-Up” test or “EAST” test. Careful examination and X-ray are required to differentially diagnose between the positional and static etiologies, first rib fixations, scalene muscle spasm, and a cervical rib or fibrous band. Additional maneuvers that may be abnormal in TOS includes moving the arms over head and evaluating for loss of radial pulses or signs of blanching of the skin in the hands indicating a decrease in blood flow with the maneuver. The “compression test” is also used, exerting pressure between the clavicle and medial humeral head causes radiation of pain and/or numbness into the affected arm.

There are several forms of treatment for patients with TOS. These may include: Chiropractic with careful nerve stretching movements performed by a qualified and experienced chiropractor with experience treating TOS. Injections with nerve blocking agents to suppress pain and reduce swelling and compression. When physical therapy and other forms of non-surgical treatment fail, surgery is the best option to restore function and alleviate pain. Learn more about surgery for thoracic outlet syndrome (TOS).

Tips to prevent TOS include 1) Avoid repetitive movements and lifting heavy objects. 2) If you’re overweight, you can prevent or relieve symptoms associated with thoracic outlet syndrome by losing weight. 3) Avoid carrying heavy bags over your shoulder, because this can increase pressure on the thoracic outlet. 4) Stretch daily, and perform exercises that keep your shoulder muscles strong. 5) Maintain good posture (ears over shoulders) 6) Practice good breathing (stomach breathing)