About Thoracic Outlet Syndrome
Thoracic outlet syndrome (TOS) is a condition where the nerves, arteries, and veins in the lower neck and upper chest area, also called the thoracic outlet, is put under pressure or compressed. This pressure can cause pain in the arm, shoulder, and neck.
Depending on the type of TOS, the symptoms of TOS can be different but may include pain, weakness, numbness/tingling, changes in skin color, swelling, muscle wasting, protruding veins, and cold hands. In more severe cases, an aneurysm or blood clots can happen.
Severe cases of TOS are rare and only a small percentage of TOS cases become severe. It's important to get a proper diagnosis from a doctor so TOS symptoms can be treated appropriately.
Thoracic outlet syndrome can have various causes and risk factors that can increase the chance of developing TOS. Let's break them down:
- Anatomical defects: Some people are born with an extra rib near their neck or have an abnormal growth of the first rib, collarbone, or a neck muscle called the scalene muscle. These defects can increase the risk of TOS by reducing the available space and putting pressure in the lower neck and upper chest area (thoracic outlet).
- Injury/trauma: Whiplash, overuse injuries, repeated overhead motions (such as jobs that require working with hands above the head), athletic injuries, and other upper body injuries can also increase the risk of TOS.
- Rounded posture: Poor posture, such as forward head positioning, "text neck," and rounded or hunched shoulders from too much screen time, can contribute to TOS.
- Lifting heavy loads: Frequently lifting heavy loads can put strain on the upper body and can increase the risk of TOS. Using proper lifting techniques and asking for help when needed can help lower this risk.
- Cancer: Although rare, the growth of a tumor in the neck can lead to compression of the thoracic outlet.
- Other factors: Overdeveloped muscles (e.g., bodybuilding), weight gain, and poor posture can put additional stress on the nerves and blood vessels in the thoracic outlet.
It's important to note that these risk factors do not guarantee the development of TOS, and individuals without these risk factors can still develop the condition. If you have concerns about your risk for TOS, it's best to consult with your healthcare professional for personalized advice.
Thoracic outlet syndrome is a condition that occurs when the nerves and/or blood vessels in the thoracic outlet are compressed. The thoracic outlet is an area between your collarbone and your first rib. The symptoms of TOS might be different, depending on the type of TOS you have.
There are three main types of TOS:
- Neurogenic TOS: This is the most common form, accounting for about most cases. It occurs when the nerves in the thoracic outlet are compressed.
- Venous TOS: This type happens when one or more veins under the collarbone are compressed.
- Arterial TOS: This is the rarest and most dangerous form, occurring when the arteries under the collarbone are compressed. It can lead to an aneurysm in severe cases.
Common early symptoms of TOS include:
- Pain: People with TOS may experience pain in the collarbone, shoulder, neck, or hand.
- Weakness: Weakness in the arm and shoulder is another common early symptom of TOS.
- Numbness/Tingling: Some individuals may experience numbness or tingling in their fingers and hand.
- Changes in hand color: Changes in the color of the hand, such as paleness or discoloration, can also occur.
As TOS progresses or becomes more severe, additional symptoms may develop. These symptoms can vary depending on which nerves or blood vessels are affected by the compression:
- Muscle Wasting: In some cases, muscle atrophy can happen in the fleshy part of the thumb or hand, where the muscles in that area shrink or weaken.
- Swelling: Swelling in the arm or hand can mean a blood clot and is a symptom that should be taken seriously.
- Weak grip: People with TOS may experience a weakened grip in their hand.
- Cold hands: Some people may notice that their hands feel cold to the touch.
- Protruding veins: In severe cases, veins in the affected arm may appear to stick out.
- Aneurysm or embolism: Although rare, severe cases of TOS can lead to an aneurysm (abnormal bulging of a blood vessel) or embolism (blockage of a blood vessel).
It's important to note only a small percentage of all TOS cases become severe. Most people with TOS will improve with exercise and physical therapy. However, individuals with vascular TOS and true neurogenic TOS may require surgery to relieve pressure on the affected blood vessel or nerve.
To diagnose thoracic outlet syndrome (TOS), healthcare providers may perform a variety of examinations, tests, and procedures. These can help identify physical signs of the condition and determine the severity or stage of TOS. Here are commonly used diagnostic methods:
- Physical exam: During the physical exam, healthcare providers look for signs of a medical problem, such as pain, swelling, or the presence of masses within the body. They may also use routine procedures to assess different body systems.
- Provocative maneuvers: Healthcare providers use specific arm and shoulder movements to reproduce symptoms of pain, paresthesia (abnormal sensations), or pulselessness that are characteristic of TOS. Common maneuvers include the elevated arm stress test (EAST), upper limb tension test (ULTT), and Adson test.
- Bony examination: This involves evaluating the cervical and thoracic spine, first rib, and different joints of the shoulder area to look for any bone problems that may contribute to TOS.
- Muscular assessment: Healthcare providers check the strength and coordination of muscles in the neck, chest and shoulder, such as scalene muscles, pectorals, trapezius, and shoulder girdle muscles.
- Neurological examination: This includes testing reflexes and sensation in patients with suspected TOS. A loss of the ability to feel vibrations is especially a warning sign of TOS.
- Imaging studies: Healthcare providers may order imaging studies like X-rays, CT, or MRI scans, along with ultrasounds to check the thoracic area and see anything out of the ordinary. For TOS, standard X-rays is used to check for cervical ribs, while ultrasound is used to study narrowing in the blood vessels.
It's important to follow up with your healthcare provider if your symptoms worsen or change after your initial examination. They will guide you through the necessary steps for diagnosis and treatment based on your specific situation.
The goals of treatment for thoracic outlet syndrome are to reduce symptoms like pain and numbness and improve the overall quality of life for individuals with this condition. Treatment options for TOS include:
- Physical therapy: Physical therapy is a common treatment option for TOS. It focuses on strengthening and increasing flexibility in the shoulder and neck muscles. Physical therapy can help improve posture and expand the thoracic outlet, relieving pressure on blood vessels and nerves. This can help reduce pain and improve a person’s movements and function.
- Medication: Over-the-counter anti-inflammatory medications, such as ibuprofen or naproxen, can help reduce swelling and relieve pain. In some cases, doctors may also prescribe thrombolytic drugs to break up blood clots, or anticoagulants to prevent the formation of future clots.
- Surgery: If symptoms do not improve with medication and physical therapy, surgery may be necessary. The type of surgery will depend on the underlying cause of TOS. One common procedure involves removing a section of the first rib and, in some cases, part of the neck scalene muscle. Vascular reconstruction may also be performed if there is damage to arteries or veins. This involves replacing a damaged blood vessel with a new vessel, called a graft.
- Health behavior changes:
- Posture correction: Maintaining good posture can help relieve symptoms by reducing pressure on the thoracic outlet. This includes sitting up straight, avoiding slouching, and engaging in exercises that strengthen postural muscles.
- Strengthening exercises: Specific exercises targeting the upper back and shoulder muscles can help improve strength and stability in the affected area.
- Stretching exercises: Stretching exercises can help increase flexibility in the shoulder and neck muscles, relieving tension in the thoracic outlet.
- Ergonomic modifications: Making adjustments to workstations or daily activities to ensure proper posture can reduce strain on the shoulders and neck.
It's important to note that the type and severity of TOS will determine which treatment options are recommended. For example, physical therapy is often recommended as a first step for those with neurogenic TOS, while surgery may be required for individuals with venous or arterial TOS.
It's important to work closely with a qualified healthcare professional to determine the most appropriate treatment plan based on individual needs and circumstances. They can provide personalized guidance and recommendations tailored to each person's specific condition.