An overview of thoracic outlet syndrome.
Buzzing, tingling, numbness and pain in your arm and hand can be very worrisome, especially if you have never experienced this before and don't know what is causing it.
A common cause for these symptoms is thoracic outlet syndrome (TOS). TOS can be caused from either a compression of the neural and/or vascular structures that pass through the thoracic outlet. We are going to focus on the neural component today as that is the most common, but just know that if your hand is turning blue and is cold you should probably get that looked at.
So, what is the thoracic outlet? The thoracic outlet is defined by the space bordered by your first rib, your clavicle (collar bone) and the superior border of your scapula (aka the top of your shoulder blade). The outlet passage is further defined by the interscalene interval, which is a triangle formed by the scalene muscles.
As you can see, there is a lot going on in this little area and multiple points at which the nerves and blood vessels can become compressed. Common sites of compression include between the scalene muscles, between the first rib (or presence of a cervical first rib), the clavicle and subclavius muscle, or at the coracoid process and pectoralis minor.
You can also have multiple points of compression of peripheral nerves (nerves in your arm) between the cervical spine and your hand, in addition to the thoracic outlet. This is called double crush syndrome or multiple crush syndrome, depending on home many sites of compression there are. This means you could potentially have TOS, and ulnar nerve compression, and carpal tunnel syndrome, for example.
So now that we know a little bit of background of TOS, how do you know if you have it?
Symptoms can vary widely depending on what is compressed and where the compression is. The most common complaint is typically diffuse arm and shoulder pain, especially when the arm is raised above shoulder height.
Another common complaint is tingling, numbness or an "electric shock" in the shoulder and down the arm. These symptoms can also occur in the neck and jaw as well.
Does this sound like you? Schedule an appointment with us today!
Causes of TOS are typically divided into four main causes and can sometimes be interrelated:
1. Congenital abnormalities: which include bony or muscular changes (e.g. cervical first rib, anterior scalene or sickle-shaped middle scalene).
2. Post-traumatic causes: this can be macro trauma such as a car accident or micro trauma such as a muscle strain of the scapular stabilizers (see my last blog for details on that).
3. “Functional” or acquired: this is from repetitive movements or prolonged postures (e.g. sitting in one position for too long).
4. Other acquired causes: These are rare but must be systematically considered as well. These include tumors hyperostosis, osteomyelitis, etc. The diagnosis for these is made by your physician and is based on clinical examination and medical imaging (CT and MRI).
So how is TOS diagnosed?
TOS is a clinical diagnosis which means that it is made almost entirely from a subjective history and a physical examination.
The examination will include different tests such as a visual inspection of the shoulder and spine; active and passive range of motion of the cervical and thoracic spine as well as the shoulder, elbow and wrist; palpation of different structures; a thorough neurological examination that looks at deep tendon reflexes as well as any sensory or motor deficits; breathing pattern; assessment of the first rib and clavicle; position and movement of the scapula as well as the strength of surrounding muscles; other tests are also performed to rule out any coexisting pathologies such as a peripheral nerve entrapment or cervical radiculopathy.
While all of this can seem daunting and scary, the good news is that in most cases TOS can be treated successfully with physical therapy. In rare cases surgery may be indicated if symptoms are progressing or if they are unresponsive to therapy.
Physical therapy treatment of TOS can include correction of any postural abnormalities of the spine and shoulder girdle, strengthening of the scapular stabilizers (i.e. serratus anterior, rhomboids, middle/lower trapezius and rotator cuff muscles), stretching of any short and tight muscles (typically on the front of the shoulder such as the pectoralis minor), as well as mobilization and manual therapy to the shoulder complex as well as the first and second ribs.
Here are some great exercises that help with thoracic outlet syndrome:
Here at Kaizen, we have worked with hundreds of patients just like you who have had shoulder pain and are concerned, frustrated and don't know what to do. We utilize the Kaizen 3 step process:
The Kaizen 3 Step Process
Step 1: Find The Source and Relieve Your Pain
Step 2: Fix The Root Cause Of The Problem
Step 3: TeachYou How To Keep It From Coming Back!
We offer 60 minute sessions, working one-on-one with Dr. Ladd to determine your problems, set goals and develop a personalized plan of care. This hassle-free process reduces the number of needed appointments, saves you time and saves you money.
It's time to get you back in the game and keep you there.
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Dutton, M. (2008). Orthopaedic Examination, Evaluation, and Intervention: Second Edition (2nd ed.). United States: Mcgraw-hill.
Laulan, J., Fouquet, B., Rodaix, C., Jauffret, P., Roquelaure, Y., & Descatha, A. (2011). Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. Journal of occupational rehabilitation, 21(3), 366–373. doi:10.1007/s10926-010-9278-9
Dr. Ladd's views on performance improvement, injury prevention and sometimes other random thoughts.