What is Thoracic Outlet Syndrome?

Thoracic outlet syndrome might be caused by injury, overuse of your arm, or poor posture. Some typical symptoms are arm/hand pain, numbness, and weakness. The diagnosis of thoracic outlet syndrome is often missed even by experienced doctors. One of the reasons is that the symptoms can look a lot like other problems, such as muscle strain.

The correct diagnosis of thoracic outlet syndrome is critical as it can lead to chronic pain and limb dysfunction.

The Thoracic Outlet

A bit of anatomy helps explain what causes thoracic outlet syndrome (TOS). At the base of your neck there is a space between your collarbone (clavicle) and first rib. This space is called the thoracic outlet. A bundle of nerves, arteries, veins, and muscles pass through this passage. Since the space is tight, any change in the anatomy can cause a compression of structures in the thoracic outlet.

Heated Debate

Before we get into the specifics about TOS, it’s important to realize that within the medical community there is significant debate about the syndrome. For example, surgeons make the diagnosis of TOS 100 times more frequently than neurologists. One of the reasons for the confusion is that the name “thoracic outlet syndrome” is very non-specific. It really only describes an anatomic region of the body, and the problems that affect the area are diverse.

For example, if you were in an accident and had an arm injury, damage to a bone is treated differently than a damaged blood vessel. The same applies to TOS; symptoms and treatment vary depending on which structure is affected.

What Are The Symptoms Of Thoracic Outlet Syndrome?

If you think about the anatomy of the thoracic outlet, you can imagine what TOS symptoms might look like. Most of the symptoms are based on a nerve or blood vessel being pinched. For this reason, doctors divide the symptoms into two categories: neurological and vascular.

Symptoms of neurological TOS may include:

  • Wasting away of the muscle at the base of your thumb (Gilliatt-Sumner hand)
  • Numbness or tingling in arm or fingers
  • Sharp, stabbing, burning pain or ache in armpit, neck, shoulder, hand, or back
  • Decreased grip strength

Symptoms of vascular TOS may include:

  • Bluish discoloration of hand and/or arm
  • Arm pain and swelling (may be from blood clots)
  • Blood clots in the blood vessels
  • Finger or hand looks pale due to poor circulation
  • Weakened or absent pulse in one arm
  • Cold fingers, hands or arms
  • Arm tires easily with use
  • Numbness or tingling in your fingers
  • Weakness of arm or neck
  • Throbbing lump near your collarbone
  • Eye problems and transient vision loss associated with head position.

Over 90 percent of TOS cases are neurological in nature while the remainder are vascular. As you can tell by the symptom description, TOS can be very serious. We can also see why making the diagnosis is difficult since the symptoms are highly varied.

What Causes Thoracic Outlet Syndrome?

The most common causes of thoracic outlet syndrome are:

  • Inherited anatomical defects – You could be born with an extra rib located above the first rib. Or you might have a very tight band of fibers connected to your rib.
  • Poor posture – Shoulder droop or extending your head in a forward position (like when using a computer) can cause thoracic outlet compression.
  • Injury – Car accidents or falls might alter your thoracic outlet anatomy. Symptoms often appear some time after the accident.
  • Repetitive activity – Using a computer, assembly line work, lifting things above your head, stocking shelves, or carrying a heavy backpack.
  • Sports injury or repetitive movements (baseball pitching, swimming, etc.)
  • Obesity can place excess stress on your thoracic outlet.
  • Pregnancy – Your joints change during pregnancy. Thoracic outlet syndrome may occur with pregnancy.
  • Tumors – In rare cases a cancerous growth can compress the structures in the thoracic outlet.

How Is Thoracic Outlet Syndrome Diagnosed?

Detecting TOS is not easy, but prompt diagnosis is essential. Diagnostic delay can lead to worsening symptoms or even permanent disability. The correct diagnosis of TOS might include the following tests:

  1. History and physical exam – Your doctor will ask you about your symptoms, and then examine you. A complete exam of your neck, arm, pulses, skin coloration, range of motion, and strength can help decide about further tests.
  2. Provocation tests – Your doctor might ask you to try certain movements or head positions to see if this provokes symptoms.
  3. Imaging tests – These could include x-rays, MRI, CT scan, or ultrasound tests. Angiography or venography is a test where a special dye is injected into your blood vessels to make them show up on x-ray. All these tests could help detect if there is a compression of structures in the thoracic outlet.
  4. Electromyography and nerve conduction – These test the electrical activity in certain muscles or nerves. This could help diagnose a pinched nerve due to TOS.

One of the keys to diagnosing TOS is for your physician to have a high level of suspicion for the syndrome. A stroke may cause similar symptoms, but the steps to diagnose a stroke are completely different. It’s important for doctors to consider TOS if any of the symptoms are present.

How Is Thoracic Outlet Syndrome Treated?

If at all possible, a conservative treatment approach is preferred. This could include:

  • Physical therapy – The goal is to regain function in the affected areas, reduce symptoms, and to minimize thoracic outlet pressure. Some methods used are posture improvement and exercises to increase strength and range of motion. Some therapists also use heat, ice, and infrared treatments.
  • Medications – Anti-inflammatory drugs and muscle relaxants might give you some relief while you undergo therapy.
  • Anticoagulants – If it’s detected that you have a blood clot, you may need medication that dissolves the clot. Also, your doctor will likely recommend that you continue to take medication that “thins” your blood to prevent future clots from forming.
  • Injection of botulinum toxin (botox) into the area has been shown to help some temporarily while physical therapy takes effect.

What Exercises Can I Do At Home?

Some common stretching exercises used to treat TOS are as follows (make sure you consult with a doctor or physical therapist before doing these exercises):

  • Shoulder stretch – Move your shoulders forward as far as possible (hunch) then back to a neutral position. Next, move your shoulders back as far as possible (arch) then back to neutral. Finally, raise your shoulders as high as possible (shrug) then back to neutral. Repeat this cycle several times.
  • Scalene stretch – Tilt your head to one side while lowering the opposite arm. Hold the position for a few seconds and return to neutral position. Do the same on the other side. Repeat several times.
  • Chest expansion – Open up your chest and shoulders by lying on a cylindrical mat or rolled up towel in line with your spine. Your shoulders will naturally fall back towards the ground to open up your thoracic outlet.

While you do the exercises, envision that your thoracic outlet is opening up. Visualization may help improve your form while doing the exercises. It may also help you become more aware of your posture in general.

How Successful Is Conservative Therapy?

A review of 13 studies published between 1983 and 2001 found that approximately 90 percent of patients had “good” or “very good” results with conservative treatment for neurological TOS. Still, some people who suffer from TOS may experience symptoms long term.

When Does Thoracic Outlet Syndrome Require Surgery?

In severe cases of TOS that don’t respond to conservative measures, surgery might be the only option. Surgical intervention is used only as a last resort. The thoracic outlet is difficult to reach surgically, and complications in the area might lead to other problems.

How Can Thoracic Outlet Syndrome be Prevented?

Even before symptoms begin, take precautions to prevent TOS. Some of the best strategies are:

  • Practice good posture.
  • If you use a computer, make sure your elbows are at a 90-degree angle while typing. When looking straight ahead, your eyes should focus on the upper third of the computer screen.
  • Take frequent micro breaks – Especially for computer and assembly line work. Stop and stretch your neck, arms, and back.
  • Avoid using heavy backpacks or bags that hang from your shoulder.
  • Try not to work in cramped areas that allow limited body movement.

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