Thoracic outlet syndrome

Hand pain

Thoracic outlet syndrome

Thoracic Outlet Syndrome

Thoracic outlet syndrome is the presence of hand and arm symptoms due to pressure against the nerves or blood vessels in the thoracic outlet area.

The thoracic outlet is the space between the clavicle and first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. Compression or narrowing of the thoracic outlet can cause a variety of symptoms which together are known as thoracic outlet syndrome.

Pressure may be due to an extra cervical rib or because of a tight fibrous band that connects the spinal vertebra to the rib. There may be pain in the neck and shoulders, and numbness in the last 3 fingers and inner forearm.

Thoracic outlet syndrome is usually treated conservatively with Physiotherapy.

What causes Thoracic Outlet Syndrome?

Thoracic outlet syndrome has been described as occurring in a diverse population, although it is more common in women than in men. It is most often the result of poor or strenuous posture but can also result from trauma or constant muscle tension in the shoulder girdle. It can also be a result of a congenital problem such as an abnormal first rib.

Compression occurs when the size and shape of the thoracic outlet is altered. The outlet can be altered by exercise, trauma, pregnancy, a congenital anomaly, an exostosis, postural weakness or changes.

Psychological changes are often seen in patients with thoracic outlet syndrome. It is not clear whether these changes are a cause or result of the syndrome.

What are symptoms of thoracic outlet syndrome?

Symptoms include neck, shoulder, and arm pain, numbness, or impaired circulation to the extremities, pain can extend to the fingers and hands. Patients can have a wide spectrum of symptoms from mild and intermittent, to severe and constant.

Symptoms of thoracic outlet syndrome may include:

  • Pain, numbness, and tingling in along the inside forearm and the palm (C8, T1 dermatome)
  • Pain and tingling in the neck and shoulders
  • Signs of poor circulation in the hand or forearm
  • Weakness of the muscles in the hand
  • Increase ache in neck and shoulder at night
  • Increased symptoms with carrying & lifting above the shoulders
  • Symptoms may be reproduced when the arm is positioned above the shoulder or extended.

Diagnosing Thoracic Outlet Syndrome

There are three types of Thoracic Outlet Syndrome. The type depends on which structure is compressed – nerve, vein, or artery.

95% of cases of TOS are due to compression of the nerves to the arm – Neurogenic Thoracic Outlet Syndrome.

The diagnosis of thoracic outlet syndrome is suggested by the symptoms and supported by findings during the examination including reproducing symptoms with maneuvers of the arm and neck and palpation at the first rib.

Special tests include: Elevated Arm Stress Test, Allen test, Adson or Scalene Maneuver. Physiotherapists are well trained in the diagnosis and treatment of Neurogenic Thoracic Outlet Syndrome.

For a definitive diagnosis imaging tests including x-rays, CAT scans, MRI scans, and ultrasound may be required.

4% are due to obstruction or clotting of the subclavian vein, a condition called Venous Thoracic Outlet Syndrome which is distinguished by swelling of the entire arm, plus pain and dark discoloration.

The third type, Arterial Thoracic Outlet Syndrome, is the rarest type, occurring in 1% of cases, and it is due to disease in the subclavian artery. Almost all cases are associated with an extra cervical rib or an abnormal first rib. Arterial Thoracic Outlet Syndrome presents with pain, coldness, and a pale discoloration of the hand, cramps may also occur when using the arm for activity.

Venous and Arterial Thoracic Outlet Syndrome are best diagnosed with the aid of specific tests, venography for venous and pulse volume recordings or arteriography for arterial TOS.

What is the Treatment for Thoracic Outlet Syndrome?

With Neurogenic Thoracic Outlet Syndrome the first treatment is always conservative as the majority of cases are caused by muscle imbalances and poor posture. Patients usually respond successfully to physiotherapy in conjunction with pain and or anti inflammatory medication.

Physiotherapists are specially trained in the treatment of thoracic outlet syndrome, and their evaluation of the patient can be helpful to determine the structures involved.

Treatments include a variety of exercises that effectively stretches open the tissues of the thoracic outlet. Physio treatment may include mobilizing the 1st rib, cervico-thoracic joint mobilisation, neural stretching, myofascial release and trigger point therapy.

Some patients with severe symptoms respond to additional taping, or braces that elevate and retract the shoulder girdle.

Weight loss, training diaphragmatic breathing, postural re- education and modifying the patients work site may also be appropriate.

Venous Thoracic Outlet Syndrome is usually treated with thrombolysis and anticoagulants, or sometimes treated by surgically opening the vein and removing the clot. Once the clot has been removed, the surgeon may recommend that the first rib be removed, or an angioplasty may be indicated.

Arterial Thoracic Outlet Syndrome is usually treated surgically; the vascular surgeon may repair the subclavian artery or replace it with an arterial graft. In addition to fixing the damaged artery, the abnormal rib must be removed to prevent the artery from being damaged again.

Thoracic Outlet Syndrome At A Glance

  • Thoracic Outlet Syndrome is a condition whereby symptoms are produced from compression of nerves or blood vessels, or both, because of an inadequate passageway through the thoracic outlet.
  • Symptoms include neck, shoulder and arm pain, numbness, or impaired circulation to the extremities.
  • Diagnosis of thoracic outlet syndrome is suggested by the symptoms and physical findings and is sometimes supported by electrical and/or radiology tests.
  • Treatment of thoracic outlet syndrome is usually successful with Physiotherapy.
  • Physiotherapy will address muscle imbalance and posture, and included stretches & exercises to prevent re-occurrence of symptoms.

All HNA physiotherapists are highly skilled in the Assessment, Diagnosis and Treatment of Thoracic Outlet Syndrome.

We offer a complete solution to your patients’ problem, including treatment, activity modification and rehabilitation.

Please contact Noosa Sports & Spinal Physiotherapy Centre for further information on our services.

Information compiled by HNA Physiotherapist Kelly J Woosnam. References available on Request.

Peter Hogg

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